Ethical way of taking history from a patient with a classical case

This is to all the doctors and medical students in the world, let's go back to the days of your medical school...

I joined Seth GS Medical College and KEM Hospital in 2013 and in the last 4 years I have had the privilege of interacting with two good conditions on two separate occasions.

One was Dr Michael Glynn, Consulting Physician, Gastroenterologist and Hepatologist, Barts Health NHS trust England. He is also the co-editor of Hutchinson's clinical methods.

And the other one was Dr Ravi Ramakantan, Director of the department of Radiology at Kokilaben Ambani Hospital in Mumbai.

On two separate occasions of a guest lecture students asked them the question ie:
" When we medical students go to take cases to the clinical wards, we see that lots of medical students gather around the same patient who generally has a good classical history and examination findings and they fail to see the discomfort and inconvenience they are causing to the patient. This is especially true before the practical exams. How do we prevent this or decrease the agony to the patient?"

Frankly speaking this is a very difficult situation. But the two vastly contrasting answers and I got from these two clinicians, has been etched in my mind.

Dr Michael firstly agreed that it is indeed a very difficult situation. He suggested that may be a first person can take a video while the other person is taking a history and eliciting examination findings, and the other person can see the video although he pointed out that watching the video will not be as much educational as taking the history first hand.

However Dr Ravi Ramakantan said, you can go and talk to the patient and develop a special bond with him. You should show the patient how much do you care for him. Of course it is an art to engage with the patient. But once you succeed in doing that the patient with himself or herself tell you the agony that he faces and will allow you to examine him/her.

Disclaimer- these are personal first hand accounts. I thought that sharing these answers with everyone we help thousands of medical students who are facing the same problem. It is in the interest of the students as well as the patient that I have written this. I may not have perfectly reproduced the words and the sentences spoken by them and this is just my interpretation of the same.

In a way, both the answers show the empathy that is needed. The first one tells you should not go ahead when the patient is not at ease. The second answer asks you to understand the same pain that the patient is going through and wait is a patient is ready.

We medical students, still have a lot to learn from the stalwarts of our own institutions, in the field of medicine.

Updates to RNTCP Guidelines

Recent changes in Tuberculosis guidelines 2016

1. 3 new goals – cure, prevent resistance and break chain of transmission.

2. Introduction of daily regime.

3. Definition and treatment of mono and polyresistance apart from MDR and XDR Tuberculosis.

4. Treatment in CAT 1 – 2(HRZE) + 4 (HRE) : Continue ethambutol in continuation phase too.

5. Treatment in CAT 2 – 2(HRZES) + 1(HRZE) + 5 (HRE).

6. Introduction of Bedaquiline as a new drug. ATP synthase inhibitor specifically targets myc. Tb. Indicated in age more than 18 years. Contraindicatef in pregnancy and those taking hormonal OCP. It may be given in patients with stable arrythmia.

7. Definition of presumptive tuberculosis. Duration > 2 weeks etc.

8. New algorithm to diagnose Tuberculosis – pulmonary, extrapulmonary, drug resistant.

9. Introduction of Newer molecular methods like CBNAAT and line probe assay in diagnostic algorithm apart from smear microscopy and chest Xray.

10. Diagnosis of tuberculosis based on X-ray will be called as Clinically diagnosed tuberculosis.

11. Sputum should be around 2ml and preferably be mucopurulent.

12. Follow up – New and previously treated Drug sensitive pulmonary tuberculosis – No need to extend Intensive phase, sputum microscopy at end of IP and end of treatment, weight monthly, chest x-ray if required.

13. Follow up – MDR tuberculosis – sputum smear monthly 3,4,5,6,7 months in intensive phase and at 3 months interval in continuation phase 9,12,15..., extend ip phase by maximum 3 months total of 9 months.

Some more additions to it, adding here which might help to pg students.

1)monitoring health status of Tb treated patients (for recurrence of tb) for 24 months after treatment
2) online monitoring of treatment adherence through 99dots programme (currently it is on pilot basis running for tb-hiv patients)
3) intensified tb case finding in clinically, socially and geographically vulnerable population. It's a provider initiated activity.
4) now 'tb suspect' term is replaced by 'presumptive Tb case'.
5) in diagnostic algorithm sputum examination along with chest x-ray is recommended.
6) 'NSP' term is replaced by 'microbiologically confirmed case'
7) NSN and others r called now onwards 'clinically diagnosed tb' case. (terms replaced)
8) definitions of cured, defaulted, treatment completed, failure, failure to respond, loss to follow up are somwhat changed.
9) cat I, cat II, cat IV terminologies r obsolete n replaced by drug sensitive (new or previously treated) and drug resistant tb categories.

Disclaimer:
I had received this message on WhatsApp. I haven't compiled this.

Acute or chronic?

No matter how much clear today's evidence based medicine gets, one thing will be always hazy.

Acute, subacute and chronic are concepts related to time. Thus they relative to each other.

A bout of vomiting that began 1 minute ago is acute, and so is acute chest pain since 1 hour. But when a young man complains of back ache since yesterday, will it cease to be acute?

A look at the dictionary will tell you "acute" can be used in two different ways :
1.
(of an unpleasant or unwelcome situation or phenomenon) present or experienced to a severe or intense degree.
Example-
"an acute housing shortage"

2.
(of a disease or its symptoms) severe but of short duration.
Example-
"acute appendicitis"

Acute is derived from the Latin word "acus" which means"needle", thus auguring well the above two meanings.

Similarly, the meaning of chronic on Google is

- (of an illness) persisting for a long time or constantly recurring.
Example-
"chronic bronchitis"

Chronic is derived from Greek "Khronos" which means "time", again matching with the meaning.

Subacute is vaguely defined as something that is between acute and chronic.

Point to be noted is that - all these three words are "adjectives" and not "adverbs". Thus they describe the noun ie the patient or the disease and not the "verb" or the action that the disease is causing.

Acute Appendicitis tells you that the patient suffered from SEVERE Appendicitis FOR A SHORT TIME. And not that "it progressed quickly".

Similarly Chronic Bronchitis tells you the patient has Bronchitis that recurred many times over a period of time or is present since a long time. It doesn't mean that "there was an episode of bronchitis 1 year ago".

Many doctors use a simple Funda -
Acute - minutes to hours
Subacute - hours to days
Chronic - days to weeks.

However this "minutes to hours to days to weeks" stands for progression of disease and not "how many hours or weeks ago he had that episode".

I hope this clarifies the long standing confusion on this topic.

# whenever in doubt, refer to the etymology of the words #

Second opinion OPD

The OPD naming has evolved over the years to reflect the need of the patients.

For layman, OPD is the out patient department, where doctor examines the patients and prescribes medicines. Most OPDs don't have special names. Some can be broadly divided into new patient opd, where taking detailed history takes a lot of time and follow up patient opd where usually the patient is well controlled on treatment and keeps following with the doctor just to screen and pick up any new disease early or sometimes for dosage adjustments.

But you can also find other OPDs like usual (read 'rich') OPD and poor patients OPD.

But looking at the knowledge explosion, patients consider themselves as "i-know-all". Thus they don't trust the doctor.
Also, increasing mistrust leads to erosion of doctor- patient relationship.

The breed of Family doctors is soon become extinct and everyone wants to rush to specialists and super specialists. Thus, patients End up consulting more than one doctor.

Also with rising affluence, the average Indian wants the best health care to be provided for which he is ready to loosen his strings.

The day isn't far, when doctors will keep separate time slots for second opinion, for unsatisfied patients coming after talking to another doctor - the future of second opinion OPDs!

Does repeated case presentation help a medical student?

My friend in postings, had presented the same case 4 times to various professors during our medicine postings, because other students hadn't prepared their cases. Did he became better each time presenting the same case?
That, the teacher will decide, but he almost learnt the entire case by heart eventually. Ml

So, if someone has presented lots of cases during the years of MBBS clinical postings, does that student become better at case presentations / better clinician or it just doesn't matter??

I think it's a sigmoid curve with a plateau. Initially you'll become better and better at presentation but eventually it will saturate. Then only the right lobe of brain and the flow of thoughts in a person's mind will be helpful in marginally increasing the presentation skills.

UG vs PG medical student

UG : Undergraduate medical student, ergo is doing his MBBS

PG : completed MBBS and now doing MS or MD

The difference is that, UG sees patients horizontally and PG sees patients both horizontally and vertically.

UG sees ample number of patients but he usually makes contact with a particular patient only once during the patients treatment course.
Thus, he can decipher the clinical signs seen in the present.

When a PG gets to follow up a patient, he knows what was his history. Many a times, you many even get to hear an anecdote about that patient
( woh patient jo file bhul Gaya tha pichale Baar..... Or ... One who had troubled a lot).
The PG knows the course of the disease better by following up with patients. And this also gives him a sense of worthiness that he is actually making a difference in someone's life when he sees patients getting better and go home.

The PG who also has empathy develops a third dimension of connect with the patient and gets totally immersed in the 3D world of health care around himself which is full of heart warming stories of doctor-patient relations.

History of Bombay

http://dsal.uchicago.edu/reference/gazetteer/

This is just superb!

Aut inveniam viam aut faciam

"Aut inveniam viam aut faciam" is Latin for "I shall either find a way or make one." The first word "aut" may be omitted, corresponding to omitting the English word "either" from the translation.Wikipedia

Cognito ergo sum

Cogito ergo sum is a Latin philosophical proposition by René Descartes usually translated into English as "I think, therefore I am". Wikipedia

Cresentric Glomerulonephritis

In rapidly progressive Glomerular Nephruty (RPGN) also known as Crecentric Glomerulonephritis is due to proliferation of parietal epithelium of glomerulus and thickening of Basement membrane.

Why is it always in Crecentric shape? I mean - "Why not like a ring"?

Maybe the answer lies in the Gaussian curve? All points in the 360 degree of glomerulus has an equal chance of being affected by the injurious stimulus , and once affected the proliferation peak is the maximum at the point of injury and decreases evenly as we move away from that point ?

Having said that, I haven't been able to find a case of Rapidly Progressive Glomerular Nephritis which is not Crecentric in shape. 

Customised gifts? Now customised surgery...

With increasing amount of options being available to the consumer at their fingertips, they are spoilt for choice.
Also as the consumer becomes more literate, and more vigilant (thanks to so many activists campaigns), health care may just be the next step.

1 January, 1990 : no wraps or burgers
Post 1991 : just choose which meal you want to eat
2017:

At Subway : first choose your bread and its length, then specify the fillings and finally the sauces.
In the hospital : the patient Just gives his consent for the surgery without asking any question

Year 2037 :
While the subway story might still remain the same
There will be a revolution in doctor patient relationship
Here is how it may sound like....

Scene 1-
Doctor : You have right sided uncomplicated reducible inguinal hernia

Patient : what are the treatment options ?

Doctor :
Please create your account and log into our app, where you will have complete control over your healthcare.
I hope you have an Aadhar card, it's compulsory for registration you see. Else I can't treat you.

After registering, you will have to link your insurance details and bank account details to authorise bank transactions. The app will debit 50% of your amount directly, while the remaining 50% had to be paid in cash (hints as- under the table)

Please note that Hernia surgery has been placed under 18% GST. All life saving procedures are free, basic and common surgeries like trauma cases have 5% GST. And sinful cosmetic and luxurious surgeries have 28%.

Now,  select the date. We have preferential and a dynamic price system for booking the date. Just like it existed while booking flight tickets 20 years ago. Pay higher fee for a better date.

Choose whom you want to be operated by. You'll find the list of surgeons on the app. The surgeon with the highest user ratings will be the costliest.

Select the chain of Hospital, location of Hospital, type of room, other facilities in the room. You can use coupon codes of new upcoming Hospitals to get discount.  Use code "GET50OFF". Offer valid till 60 days.

Various suture materials are listed, with advantage and disadvantage of each along with the cost. Select which suits you.

The size of the incision. No brainer that you'll have to pay more for smaller incisions.

After every 30 mins in the OT, the surgery will stop and 2 mins of advertisement will be shown. If you do not wish to see ads, please use the "paid version of the app".

Give video consent on the same.

(The patient selects as per his budget and his needs, weighing pros and cons of each aspect using terabytes of evidence based medicine to customise his surgery for him)

At the end, he hits "submit" button and an acknowledgement message appears.
        "Your order has been accepted. Our customer service representative will get in touch with you shortly. THANK YOU FOR SHOPPING WITH US"

Theory of exponential rise of knowlegde

The most learned person says he knows the least, while the least learned person will be totally ignorant of the things he doesn't know.

Thus, it's aptly said that- "He who knows what he doesn't know, is the wisest"

Another aspect of learning is, how it rises exponentially.
We take 3-4 years to learn to make simple lines. It takes us 1 year to learn alphabets in the Kinder Garten. Then, in the next few years we have lesrnt 2-3 languages and basic arithmetics.
In your secondary school, you learn entire subjects within semesters. And now, looking at the books of degree college, 10th std science text book seems to small. When Guyton seemed to difficult to carry because of the size, we hadn't seen Robins which could break backs. And then you reach the level of Harrison's and Bailey & Love, the heavy voices in their fields, little do we anticipate the gargantuan volumes of Review and MCQ books we ll have to solve. And it keeps getting bigger.

Science text book in SSC,
Biology text book in HSC,
Harrison in MBBS,
Braunwalds for Cardiology
ECG book for further studies and the list goes on

The scope of book becomes smaller, but the size keeps getting bigger. However the time taken to complete gets lesser.

Cautery on the brain

I saw a neurosurgery at Dr Hasan Sadikin Hospital in Bandung yesterday, 16th Feb 2017.
It was a supratentorial Sphenoorbital ? meningioma and craniotomy+cranioplasty was being done.
I was wondering if the electrical signals of cautery had any effect on the person after operation is over.

Reasons -
Nerves work on depolarization and repolatization, which is electrical activity.

We know about electrical shock therapy is psychotics as a therapeutic intervention.

Mumbai - - > Bandung

This is my second last day in Bandung and I feel this is the perfect time to share my experience

For Indonesia -

Visa : You can avail of Visa on arrival (VOA) by paying 35$ for 30 days permit.
Advice - keep all necessary documents (passport, invitation letter, card or acceptance and confirmation, Aadhar card, travel insurance, health records, health certificates, return ticket etc) along with you, in your boarded baggage not checked in baggage.
They don't accept payment by card. So keep cash with you.
Immigration officer at Bandung charged me 510,000 for visa and gave me a receipt of 35$ ( And I'm still wondering how could I have confirmed the exact conversion rate at that time. Probably the officer charged more from me. But I don't think anything can be done about this.)
Just keep 600,000 cash with you when you arrive.

Language :
Download the offline app called "English Indonesian dictionary". Doesn't use data and app size is small.
Good is you just want to see meanings of random words you see while walking or on notices, menu cards, coupons, tickets etc. Downside is that this translates individual words only. You will have to resort to Google translate for better conversation.

Sim cards:
I had bought matrix sim card from Mumbai. But it wasn't very good.
Matrix probably has tie up with local company called "Tri" or "3" in Indonesia and their network is not up to the mark.
You'll get 3G at prominent places in the city but there will be pockets of "no network" 

Money :
I had used an Axis bank forex card which is preloaded with money. Convenient but the minus point here is it will charge 2$ extra for every cash withdrawal.
And 0.03% extra on every transaction (ATM or POS machine)

For cash, better to get it converted from India. Since when I had enquired at a local money exchange shop (Dollarasia in Sukajadi, Bandung) they quoted me a price which was twice more expensive.
To give you an idea,
I got around 150 IDR against 1 INR. They quoted 95 IDR against one 1 INR.
(the actual bank rates are around 195 IDR for 1 INR)

Socket :
It's slightly different. Only 2 pins can be inserted unlike 3 pin plugs that we have.
I couldn't use my oneplus2 adapter since the pin was short. However, Samsung and Apple adapters work well.

Travel :
Download "Go-jek" and "Grab" when you arrive. And "Uber" you might have already.
These are the most popular transportation apps.
Unique feature is the two wheeler taxis like Go-jek or Uber-2 wheeler, that is cheaper than an Uber Car.
Be aware of local "Ojek" which is the traditional way of transport. They will always charge more than what you get on these above mentioned apps.

Food :
Non vegetarians, you can try chicken, beef, squids, fish, prawn, lobster, octopus etc.
If you don't want beef (sapi = cow)
You can also find authentic Chinese and Japanese restaurants here.
For vegetarians, all the best 😂
Nasi putih = plain rice
Nasi goreng = fried rice
The only traditional dishes I could eat were - Gado-Gado, Lotek and Cupchay.
For snacks - Tahu (tofu) and Tempe can also be eaten.
Say "pedas" if you want it more spicy.

Culture :
A lot of people, including teens smoke. People smoke while driving. Even your car / Angkot might just decide to smoke while driving, which can be quite disgusting.
Alcohol is a no-no in Islam however you'll find pubs at certain areas in the city.
Tea (Teh)  is what everyone drinks morning to night. You may even be given one for free along with lunch.
At all the restaurants I have been, the waiters have always asked me "what would you order for drinks? Tea?"
And the tea by default is the Indian tea. It's without milk.

Entertainment : amongst Indonesian, Chinese, Japanese and Korean movies - Bollywood has a very special place here.
Almost all the people must have seen "kuch kuch hota hai" here and "chaiya Chaiya" song had become a big hit here. So don't be surprised to here Aashiqui songs being played when you are shopping or at a cafe.
They have a lot of respect for Indians in general.

Past history : Indonesia was colonized by the Dutch. So you'll find their architecture here in old buildings.
Even the Japanese had colonized Indonesia for 3 years (maybe thats why so much of Japanese influence)

Numbering : Lentai means floor.
They don't number from Ground floor. The ground floor in Mumbai (or India) is first floor here. When someone told me go to the "second floor", I climbed one flight of stairs and couldn't find anything more above it. Because the "first floor" was actually their second floor.

Tipping :
Thankfully it's not required at any restaurants. Most of them add a service charge and I haven't myself done or seen anyone tipping at restaurants.
However, (this will be new to you), every time I see a car parking or leaving from the gate, a local person will be standing to help or assist you in parking and will make other cars wait to make way for your car. In this case you should tip that person from 2000 to 5000 Rupiah. Even if the parking was not difficult, these persons will just come and stand near the drivers window to get money and still people pay!

My Bandung experience -

Skewed data - Stats again

For those who didn't understand the photo :

Background Statistics -
A normal distribution curve is symmetrical bell shaped curve bla bla bla, which I'm sure you know

Skewed curves are seen when the distribution is not symmetrical. It can either be Skewed to the left or the right (see picture)

Now imagine a Skewed curve, depicting the average income of a person and the number of people.
When it's a Gaussian curve, you'll see that - the majority of the people will be in "middle class", some will be super rich and some will be poor.

Now what if that is actually not true? Our graph will get Skewed. This can be of two types.
1) most of the people have an income higher than the average. Mode is greater than the mean.
This is called Skewed to Left, because the graph dips on the left side. And as per the convention, left is also the negative axis. Thus we also call it negative skew.

2) similarly, when most of the people have their income that is less than the average, and very few people own a major chunk of wealth, we call it right skew or positive skew.

And here comes the Eureka moment where you compare them with ideals and philosophies.
Left wing socialists / communists to right wing capitalists.
I'll leave it here for you to ponder over it, gulp it and ruminate it 😉

To diversify : Learn from the guru itself

It's another morning when my hands involuntarily grab the daily newspaper, trying to skip a few pages of same news about worldwide protests against newly elected POTUS Trump, the page about personal finance has incited interest in me of late.

After the monotony of news regarding scams and the updates of upcoming polls, this page refreshes me with the Serotonins of happiness after learning something new - Personal Finance.

Woah bro. Calm down. Now we are going into the territory where every biology student treads with fear. Finance, Economics and Statistics.

Today's article talks about diversification of portfolios. But everyone knows the nature's secret of being able to keep the species alive.

The nature is working all the time to make infinite minute adjustments in the genotype, to adjust with the environment. The nature is perfecting her art since 5 billion years now. 

She has a mechanism of cell division called "Meiosis" that allows genetic transfer of information, allowing the offsprings to be genetically superior, evolving continuously. 

Even our HLA haplotypes, the MHC antigens present on our WBCs are so varied and diversifed already, that should a catastrophic microbiological attack happens, atleast some human being will be immune to it to propagate our species further. 

Now that's a Micro-"surgical strike" indeed