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.

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!

To the Depths of Darkness

27th February, 2016. Saturday

Third minor is that year of MBBS course when you just have to study 3 subjects : ophthal, ENT aaaaaaaaand PSM!
The journey from 'help-me-figure-out-whats-going-on' in the first year, to 'putting-your-fingers-in-every-damn-event' in the second year, I had thought that third minor should be comparatively chilled out.

From holding the necrosed ear ossicles to examining the nucleus of cataract lens, from observing into the friends' ears, to unsuccessfully trying to evert my eye lids, ENT and ophthalmology postings have already taught me a lot.

But there is this one case I saw in the ophthal OPD that I cannot easily forget. A 13 year old girl from a low socioeconomic background, a known case of B cell acute lymphoblastic leukemia, had come with endophthalmitis ie infection of inner coats of eye.

She screamed in pain as the attending doctor tried to examine it. She got herself admitted to the neighboring Tata memorial Hospital for the leukemia and had already been through 3-4 days of course of few of the strongest systemic antibiotics I knew of.

The doctor called her father and explained the need of continuing the treatment and also putting more topical antibiotics, otherwise the infection could spread to her brain. She said, "hamein jaan bachaane ki koshish karni hai pehle".
To which he asked, "aankh toh theek ho jayegi na baad mein?"

And the girl broke down when the doctor shook her head and said, "iss aankh ki roshni ke wapas aane ke chances bohot kam hai" 

I can never forget that moment. The moment of horror for that poor girl, when all her dreams must have got shattered at once.

That's when reality dawns upon me.

What Khurana or Parson never taught us was that 'the Eye' is not just an organ but the most prized possession of the body!

During the OPD in the next week, I saw that girl and run after the doctor who had seen her. My joy knew no bounds when I learnt that she was responding to the treatment!

Wonder of god

I was reading Robins the other day. And look what I found. 

The polymorphism of HLA is a wonder of God indeed. Didn't get it? I ll explain 

It states -

"it is believed that this polymorphism evolved to ensure that at least some individuals in a species would be able to display any microbial peptide and thus provide protection against any antigen"

This is an additional safeguard against an apocalypse due to an organism. Because at some one lucky people in the species will be having sensitivity to that particular antigen that rose to threaten mankind. And so those people will survive and continue the species further!!

#robinsfever #robinspathology #robinsquotes 

Why does brain control opposite halves of the body?

This picture shows three diagrams.

The circles show the retina, the lines are optic tracts and curved lines resemble the cortex

The third diagram in the picture shows what may have been the arrangement- the right cortex receives visual signals from right eye. But the images on the nasal side will be seen on the temporal retinas of both eyes, which will be seen as double. So the arrangement is not feasible.

Now we come to the first diagram, this is what actually is-

The nasal fibres (carrying impulses of temporal field of vision) cross over. 

And since right cortex receives impulses from left side, it sends motor impulses also to the left side

Now here is my question-

Why don't the temporal fibres cross?

If that would happen, the same half of brain will control same side of the body! Human anatomy could have been so much simple 

If you get answer to this question-

Plz post it as comments 

Thanking you

Future of surgery

      It's 12.39 am and I'm trying to sleep. That's when all weird thoughts start coming to our minds. And I couldn't stop my brain from thinking about the surgery of the future. I don't know how did this thought come to my "Cosmo-cortical" pathway, but that was enough to fire some corticospinal neurons to direct my hand to pick up my phone and begin writing. 

       If we can manage to miniaturise the robots and teach them how to...

      Hey wait, it just occurred to me how did I begin thinking of this-

I had this doubt about- why the peritoneal cavity in females is open. I finally got the answer in embryology. That reminded me of what a sir in my college had commented about embryology, "embryology is not real. There's nothing like embryology. All what we are studying is abstract". That lead me to pondering over the fact that our embryology is limited to- explaining why the defects occur and the underlying basis of that anomaly. (How fascinating it is that we don't need to think of the whole sentence to think of that whole sentence that my sir had told. In a jiffy, I am reminded of all the words that my sir had told. I mean, to recall an entire day of your life, you don't need to spend that much time recalling it, it will take the same amount of time as you take to recall one word! That's just by the way). Then I started thinking of-if we would use knowledge of embryology to help people. Then it came to surgery while an embryo is still growing. But how can a human approach it? So I thought of robots. Microbots, the size of bacteria may be handy at that time. 

   After making giant leaps in the sphere of technology, we may one day be able to produce robots that have the capability of normal robots. Storing power, computing, operating, commanding, seeing, hearing, connecting and doing its job. 

     So imagine, a women is on the operation table half a globe away from me and a friend of mine just invents a new way to fight a disease. He codes it and instantaneously sends it which I forward to the master computer over there. It is then shared to the million Microbots all piled up in an injection. They are made to connect to the computer via wifi and download the lastest technique to fight the disease. They all also can talk to each other. When first one goes in the body, he may send a message to all others like- "oh it's dark in here. Oops I just got pushed into the right coronary artery. I ll do my work over there. Take care and good luck". The other Microbot may reply, I m having some difficulty in the 8th zone of the right lung. I need backup immediately". Robots will be carrying packets of drugs that can be injected selectively into each cytoplasm. They may be able to enter the nucleus, obtain copy of the main DNA via PCR and replace the mutated DNA with the new one. 

They all will work as a team. 

   That I think will be the future of surgery. :)

Human body-the best creation ever

  Well, this blog is gonna be much of scientific or medical knowledge. But I need to take its help to prove the point.

  Before I write this, I want to say-

"I solely am a medium to convey the following information. The source is a very respected professor at my college. Dr. K. Shyamkishore"

   According to him, the makeup of the human body was predefined and decided. Saying which, he concludes that- "THUS ANYONE WHO UNDERSTANDS ANATOMY, WILL ALWAYS BELIEVE IN GOD". 

  He gives an example-

1) the sternocleidomastoid muscle-

Every muscle is innervated contralaterally, except the sternocleidomastoid (SCM) muscle. For lay people, this is a muscle of the neck. When one side of the body is paralysed (say right sided hemiplagia), then all the right side muscles except right SCM plus the left side SCM get paralysed! Paralysis of left sides SCM causes head to turn towards left, ie towards normal side.

  It would make no sense to have right side hand paralysed and keeping the head rotated to the right! You wouldn't have been able to see what you are doing with the left hand.

   Having a paralysis of right hand muscles and having the head permanently fixed towards the left makes more sense.

2) the fingerprint-

  Every fingerprint on earth is different. Even in the case of identical or monozygotic twins!!! Not only that, any single finger print is unique compared to all the prints in the past and all those in the future. This leads us to think that there's something that connects the past, present and future finger prints...this remarkable task...can only be performed by the almighty.

3) the right cerebral lobe is for imagination.  The pathway for ideas is cosmocortical tract. Cortex is connected directly to cosmos!

 A case Corpus callosum hemisection, is as good as two different people living in one!

  "THUS ANYONE WHO UNDERSTANDS ANATOMY, WILL ALWAYS BELIEVE IN GOD". 

   

Being a doctor

•What goes into being a doc?

•Is it art, commerce or science?

And the answer is- it's all the three!

  Obviously it is science first! Studying medicine requires you to study functioning of a normal body, to study pathologies, to study drugs and surgeries. 

  How is it an art? Well, an experienced physician would like to put it like this-

"Practising medicine is like driving, the more you do; the better you are at it"

 It definitely requires skill to identify the pathology as early and precisely as possible. 

  And commerce? Modern medicine has brought the commerce component to it. Traditionally medicine has been selflessly working for people! But the practice of "cuts" saddens us all.

   These descriptions of medicine are not mine. According to me- medicine only requires devotion of your life! I will also completely understand the meaning maybe after half a century later, and then I hope, when I read my blog again...my 'risorius' muscle would contract involuntarily and  leave two semilunar creases on my face!