The Family Doctor

The family doctor is fortunately being resurrected again. Yes, he was almost dead the last few decades when the public’s obsession with specialties and specialists drove them to high-end tertiary care centers. What they often missed was good holistic care!

The family doctor’s role is the most challenging. He has to answer why the newly born cries after feeds, why the school going child is losing his appetite (or at least that is what mom thinks), why the lady of the house gets the splitting attacks of migraine, how to measure and control the gentleman’s BP especially when there is tension at office, why granddad takes so long to pass urine, and how to manage the vomiting and diarrhea of the cousins who are visiting! In other words, he has to be the proverbial jack and dabble with all aspects of health from birth to death.

Being a scarce commodity, a good family doctor can be difficult to find. His qualifications should include a “proper degree” and easy accessibility. He should not be the “white coat monster” to scare the kids with injections if they don’t eat their veggies. He should be more like a family friend whom you can consult for almost anything. Another essential quality is “openness”. Considering the varied aspects he is called upon to address, he should not be expected to know everything in detail (what is a specialist there for?), but should be willing to seek help and guidance from peers, books or the net. Here is a simple test: if he looks irritated with your persistent questions, or disapproves of you finding something about an illness from the internet and bringing it up, he is not quite your guy! On the other hand, if he says he is unsure and needs to read up or consult, go for him!

The family doctor should know the unique aspects of your body system and that of your family; your allergies, the painkillers or antibiotics that agree with you, your other medical conditions such as diabetes, hypertension, hypothyroidism, peptic ulcer, proneness to fits or panic (we call them co-morbidity) that often get thrown off gear during illnesses, and your nature. Treatment or care should ideally be provided in this total context, an aspect that specialists are prone to overlook.

I find that most of the patients who come to seek treatment at a specialty center like SGPGI do not have family physicians. When I specifically ask them to find one near their homes, they appear reluctant and often seem to lack faith in their doctors.

Family medicine has indeed become a sought after specialty in the USA and Europe. In India, most bright medical graduates still seem to prefer heading for narrow specialties, but hopefully the trend will change.

Tailpiece: For specialists, patients keep changing but the diseases remain the same. For family physicians, diseases keep changing while the patients remain the same.
Published in HT city Hindustan Times(Lucknow), dated 31st January, 2010

Medical Kit for Home and Travel

The regular depiction in TV serials of a doctor arriving home immediately when summoned on telephone to attend to an emergency, could not be farther from reality. Most doctors do not attend home calls, and the chances of getting one in the middle of the night when you are down with an attack of incessant vomiting or an allergy could be almost impossible.

It makes sense therefore, to keep some medicines at home or carry on travel. Here are some tips on how to make your own emergency medicine kit:

1.      Keep medicines that you are familiar with, and preferrably, have taken before, so that it is not a first timer during an emergency and that too in a new place.

2.      If you are not good with tongue twisting drug names, put them in labelled envelopes according to indications. For example, you could have paracetamol tablets in an evelope labelled “Fever, Body pains”, or loperamide in one labelled “Loose motions”

3.      Keep them in your hand baggage, in a separate pouch or flap. I recall how a fellow passenger, who had a history of asthma, came down with a severe attack during a long flight from Delhi to Frankfurt. He had packed his bronchodilator puffs all right, but in the checked-in luggage! I had to administer an injection of deriphylline, which fortunately the emergency kit of the airline had, to him in mid-air.

4.      Know your special needs: For example an asthmatic should ensure he travels with his bronchodilators, those with diabetes should carry not just their anti-diabetic drugs but also some sweets or sugars, in case their head spins due to a drop in blood sugar.

5.      Consult your family doctor; he would know which medicines are safe and good for you.

The kit could contain medicines to deal with these common emergencies:

1.      For allergy, hives, itching, running nose, watery eyes, brochospasm: Allegra/ Alspan/ Cetriz/Avil tabs

2.      Loose motions (watery) : loperamide (Imodium)

3.      Acidity/ heartburn: Digene or Gelusil tablets/ Ranitidine or Omeprazole

4.      Nausea or vomiting : Domperidone or ondansetron (Emset MD)

5.      Motion sickness : Avomine

6.      Infections: tummy or urine infections, fever: Ciprofloxacin or ofloxacin/ cephalosporins like Cetil or Sporidex

7.      Throat or chest infections: cephaloporins or amoxycillin or Septran

8.      Fever, body aches, sprains, injury: Paracetamol/Brufen

9.      Crampy pain in abdomen or painful periods: Spasmindon, Cyclopam/ Meftal spas are some antispasmodics

10.  Also carry drops for blocked nose (Otrivin), a few Bandaid strips, a local antiseptic cream (Betadine) and a few Oral Rehydration sachets (Electral) and laxatives (like Naturolax) especially if you are travelling to the west.

11.  Make sure you have your family physician’s cell number at all times

12.  If you have any medical problem such as diabetes or blood pressure, carry these medicines in sufficient numbers. Your family doctor will guide you regarding any special medicines that you should keep for your unique needs.

The kit is like the spare tyre that you keep in the car boot on long drives. And there can be a little doctor in each of us to pull us out of unexpected health troubles!

Happiness and Health

Recent research is turning the relationship of health and happiness on its head; healthy people are ofcourse happier, but more startling is the observation that people who are happy and satisfied with their lives might be healthier.

 Moreover, the benefit comes with a quick turn around time, with greater happiness boosting health in as little as 3 years. Around 10,000 Australian adults were posed 2 questions in a study in 2001: “During the past 4 weeks, have you been a happy person?” to assess happiness, and “All things considered, how satisfied are you with your life?” to determine satisfaction. The answers were correlated with physical health parameters in 2001 and 3 years later in 2004. “We found strong evidence that both happiness and satisfaction have an impact on our indicators of health”, says Dr Siahpush, from the University of Nebraska Medical Center, Omaha, USA. They were associated with excellent or very good physical health, absence of long-term limiting illnesses, and higher levels of physical health 3 years later!

That material wealth and happiness do not go hand in hand is now well known. Bhutan’s King Jigme Singye Wangchuck first coined the concept of Gross National Happiness (GNH), an attempt to define quality of life in more holistic and psychological terms than the Gross National Product (GNP), in 1972. He convincingly argued that spiritual development was as important as economic growth and proposed sustainable development, promotion of cultural values, conservation of natural environment and establishment of good governance as the 4 pillars of GNH.

The basic concept has undergone several modifications, but surprisingly, India with its rich history and traditions of spirituality, yoga, secularism and tolerance is struggling way behind? Where did we lose our way and our values? If road rage, and squabbles from parliament to railway platforms are any indicator, we certainly do not appear happy; rather we seem perpetually enraged, demanding, intolerant and violent! Little surprise then, that India is emerging as the international capital for diseases like Diabetes, heart disease and cancers!

A good way to plan 2010 may be by assessing how happy we are at present. You could start by asking yourself the 2 questions posed above, or take a 5 minute test developed by the German scientist Dr. Grossarth-Maticek (http://www.attitudefactor.com/). The next step could be to set a goal to change some of your negative attitudes to positive ones in 2010. A study conducted by the German team showed that those who did that had a thirty times higher chance of being alive and healthy 21 years later than those who persisted with their self-destructive attitudes. It is well worth the effort! Wish you a Merry Christmas and a truely Happy New Year.

You can increase your mental health by the following:

1.Smile and laugh more

2.Don’t take yourself or life so seriously

3.Realize that if you fail, it is not the end of the world

4.Replace anger with forgiveness, greed with compassion, hate with love (or atleast tolerance)

Faith and Healing

Physicians and researchers are now paying increasing attention to prayer and its powers in healing, relegating the concept that our body and its ailments are not influenced by our minds, to history. Science is reluctantly coming to terms with observations that patients in intensive care units who were prayed for did significantly better in terms of recovery and survival than those who were not prayed for.

Neurosurgeons of LSU Health Sciences Center, Louisiana, USA, evaluated the effect of prayers on the recovery of unconscious patients admitted with traumatic brain injury. They compared 13 patients who received prayers with another 13 with equal severity of injury who did not receive prayers. The analysis showed the group who received prayers did better in terms of survival, and recovery from coma. Doctors are finally waking up. Two decades ago most medics would have discarded a patient’s or his relative’s spiritual aspirations as humbug. In a recent study from Massachussets, USA, Drs Cadge and Ecklund (Southern Medical Journal, 2009) found that the attitude of even senior specialists had become open and accommodating, almost 100% of those interviewed, respecting the wishes of the patient or family towards praying.

Critical illnesses and invasive procedures carry high risk, and doctors and nurses are beginning to accept the limitations and unpredictability of medical science and their efforts in these situations. In another eye opening study, Baumhover N and Hughes L from Arizona, USA, explored the role of spirituality among health care professionals in dealing in these settings; they found that the spiritually inclined professionals were more willing to allow the presence of relatives during invasive procedures or resuscitaion of the critically ill. Allowing the option of patients’ families to remain present by the bedside promotes holistic family centered care.

Many people use religious activity to cope with stressful life events. Dr Ayele and colleagues from Virginia, USA, analysed the scientific publications on this topic and tried to address the question,“Does religious activity really improve health outcomes?”. Based on 16 publications, they concluded that religious intervention, such as intercessory prayer improved success rates of in-vitro fertilization, decreased hospital stay and duration of fever in septic patients, improved rheumatoid arthritis, reduced anxiety, and improved outcome of cardiac disease.

Prayers may decrease our stress levels and boost our immune system. Dr Bormann and colleagues from San Diego, USA showed that prayers could bring down increased corticsol levels in patients with HIV disease. Cortisol suppresses the immune system, and bringing it down could hold promise in strengthening it and improving our fight against diseases.

Does all that I have mentioned above sound like De ja vu? something that you had guessed all along but never really had evidence for? Precisely. Many of us have ignored the teachings of our rishis, yogis and sufis as unfashionable, and shied away from accepting them. Now, research conducted in the west using modern scientific tools, is proving them correct. It is time we rediscoverd our roots and our traditional wisdom with pride.

Managing Stray Animals in SGPGIMS

When I joined SGPGI in the summer 1987, I had no patients to see. I was made chariman of the "Pig Chasing Committee". Life has come full circle with my recent elevation to a similar post. But compassionate handling of these unfortunate creations is something we can't close our eyes to. Each evening, when my pet Neal wags his tail and jumps into the back seat of my car for a ride, the orphaned, tick infested emaciated young mother of three liters on the road looks at me with doleful eyes and asks " Why don't you love me too?". And I have no decent answer!

The Department of Gastroenterology

The Department needs frequent meetings and fed backs.You could post your comments on our performance and problems as we stride to remain in top 5 in the country. 

Joint Academic Sessions at SGPGIMS

The Joint Academic Session of SGPGIMS,whose coordinator I am, needs a dash of enthusiastic revival.This platform would love to have your constructive criticisms.

Indian Society Of Gastroenterology -Thought exchange platform

As the president of the Indian Society of Gastroenterology this year (2010),this platform will enable us to share thoughts & suggestions on a frequent basis to set common targets and work together.

Celebrities and Health Awareness

Celebrities, through their own life examples, often help create awareness on health issues more effectively than can be achieved by  other means. And it is the media that plays the vtal role of taking this information to the society.

Take coronary disease for example. When Dr Manmohan Singh underwent his second cornary bypass surgery last year at the discussion in party circles often revolved around topics such as success of re-do surgeries and the effectiveness of angioplasty. When Bill Clinton underwent a similar surgery a few years ago, people came to know from his case example that saturated transfats in fast foods (he was passionately fond of burgers) tend to clog the arteries that carry blood to the heart muscles, and prevention needs to start in teens rather than in 40s.

Mr Sharad Pawar’s cheek cancer story was very telling; he was an avid Gutka chewer and what is now too well known is that this habit confers a great risk of oral cancer. In fact, India, where men chew tobaccolike cud, has the highest reported oral cancer rate in the world. What makes Mr Pawar admirable is that after the surgical removal of cancerous growth in USA that has left his face somewhat disfigured, he initiated an anti-Gutka campaign in Maharashtra to prevent other gullible chewers from reaching the same fate.

The Australian pop star Kylie Minogue’s beast cancer story is known in almost every household. As this young girl suffered the disease in her 30s (considered rather early for it as it usually occurs in 50s and 60s), the public followed media coverage of every step of her diagnosis, surgery, chemotherapy and rehabilitation with feverish interest. In fact, breast cancer awarenss got its biggest boost due to this event than any amount of government sponsored campaigns had achieved.

The story of AIDs, though somewhat old, is woth remembering. The first celebrity victim it claimed was the legenary Hollywood star Rock Hudson. The public followed his brave fight till the tragic end and learnt about how the infection spreads, how the disease occurs, how it is diagnosed and treated, and what may be done to protect ourselves.

The stigma around diabetes, blood sugar testing and insulin injections have been demystified largely by the great cricketer Wasim Akram. He was one of the 1^st to declare his disease and has campaigned extensively for its screening, monitoring and treatment. And appearing just as fit now as the bowling coach of the Kolkata Knight Riders as he did in his hay days 20 years ago, he has silently assured many that diabetes, if kept well checked, is compatible with healthy energetic life.

The British Royalty has had its own share of medical problems that the public has followed and learnt of over centuries; Hemophilia and Porphyria became known as royal diseases. Through the lives of princess Diana and Victoria Beckam, people have learnt about eating disorders, through Parveen Babi and Brooke Shields, we have learnt about Schizophrenia and Depression, from Patrick Swayze about pancreatic cancer and from Michael Jackson about drugs overdose! And many many others!!

If the community has learnt from these and other celebrities, it is the media that has played a crucial role in educating us. 

As published in HT City ( Hindustan Times) dated 10 january ,2010.

Current Activities of Stray Animal Managment Committee

Mrs. Reema Singh and Dr. Manish Tiwari from Animal Ashram visited the institute on 2nd January 2010 at 3 pm, met with the Director, Dr RK Sharma and members of the committee, and took a round of the campus to evaluate the problem.

They informed the director and the members of the following:

1. The only humane and legal way to deal with stray dogs is to prevent/reduce their breeding (female dogs often produce 3 liters every year). This can be achieved by performing a sterization operation on the female dogs.

2. They need to be transported to Animal Ashram for the surgery. It takes aroud 7-10 days from surgery to removal of stitches. They may be immunized against rabies during their hospitalization.

3. These animals will then be brought back and left in their habitats for living as before.

4. It would be desirable for local animal/stray-dog lovers to partner with them and to help them catch and take the animals for sterilization.

5. Local members should constitute an advocacy group to create awareness amongst campus dwellers abut this operation. There should be no misgiving regarding the intentions, ethicality and the nature of treatment meted out to these animals.

6. The centre has performed 245 such surgeries with more than 99% success and safety.

7. The Director, Dr RK Sharma, appreciated the efforts made by the NGO Animal Ashram and offered to provide logistic and medical support to them for their services.

8. It was decided that local advocacy group be created for sensitizing people in the campus.

     a) Type V & IV : Dr.Kumudini Sharma, Dr. Jyotsna, Dr Priti Dabadgao, Dr Piyali Bhattacharya, Dr Ujjala Ghoshal (Old campus)

    b) New Campus: Dr. Hem Chandra, Dr. Prerna Kapoor, Mr. and Mrs SN Semwal,

    c) Type II & III: Mr. Sunil Shishoo Mrs.Janet

9. Mr.Om Prakash was requested to provide a census of number and location of female dogs in the campus, within one week

10. The process could start as soon as the information was made available to Dr. Tiwari.

Dr. Prerna was requested to take a leadership role in this venture.

Drive Safely

During the ongoing Road Safety week, it is sobering to know what statistics have to say about our driving skills, behaviour on roads and the risks we pose to ourselves. While only 1% of global cars are on Indian roads, we account for 6% of the global road traffic accidents (RTA). In fact, India holds the dubious distinction of registering the highest number of road accidents in the world.  According to experts at the National Transportation Planning and Research Centre (NTPRC) the number of accidents for 1000 vehicles in India is as high as 35 while the figure ranges from 4 to 10 in developed countries.

Road fatalities have assumed epidemic proportions and are predicted to become the 5^th  highest killer in the world by 2030. An accident occurs every 7 minutes and at least 13 people die every hour in road accidents in the country, the latest report of the National Crime Records Bureau reveals. In 2007, 1.14 lakh people in India lost their lives in road mishaps — that’s significantly higher than 89.5 thousand road deaths in China. Road deaths in India registered a sharp 6.1% rise between 2006 and 2007. Road safety experts say the real numbers could be higher since many of these accident cases are not reported.

Highest deaths in India	In %	Killer States	Road deaths in ‘000
Truck occupants	22	Andhra Pradesh	13.7
Two wheelers	19	Maharashtra	13.7
Buses	11	UttarPradesh	12.5
Pedestrians	9	Tamil Nadu	12.0

Why do road accidents occur ?

·         Easy availability of license

·         Speeding

·         Punishment for speeding / errant drivers is light

·         Drunken driving

·         No helmets

·         Absence of seat belts & child restraints

·         Usage of cell phone while driving.

While both centre and state governments are pushing forward for building and constructing roads, very little is being done to ensure smooth and safe traffic in these express ways.

How can the figures come down?

·         Public awareness campaigns to improve road safety.  

·         Strictness about usage of helmets

·         Heavy fines for usage of cell phones while driving

·         Stringent laws for issuing licenses.

·         Heavy punishment for breaking traffic rules

Around 60% of RTAs are due to driver factors alone and another 30% due to a combination of roadways and driver factors. Interestingly 70% of drivers feel that their driving skills are good or excellent, but rate other drivers as dangerous. And while drunk driving continues to be the leading cause of accidents at night, use of cellphones has emerged as a major risk factor for daytime accidents.

The hazard of riding a 2-wheeler on narrow crowded Indian roads with fast cars driven by rash drivers, should be easy to comprehend. Deaths from 2-wheeler accidents occur due to injury to the head, the majority of which can be prevented by wearing helmets. It is indeed a tragedy that what makes a few young Indian 2-wheeler drivers occasionally wear helmets is not to save their heads but to avoid “harrassment” from traffic cops.

As published in HT City ( Hindustan Times) dated 3 january , 2010.

Indian Society of Gastroenterology

Report on the ISG Annual Course for Examination-going GI Trainees held in 2009

For quite some time, the idea of creating a separate program within the Indian Society of Gastroenterology specifically targeting trainees and students was under consideration. In 2008, 2 proposals came to the Governing Council for consideration and approval: one was by Prof SK Acharya and Dr Govind Makharia, and the other submitted by Prof Gourdas Choudhuri. It was also felt that the 2 programs should be complimentary to each other and benefit different segments of trainees.

Both the proposals were approved by the Governing Council in September 2008 with the suggestion that the session organized by Prof Choudhuri (as initial program director) cater to examination going DM and DNB trainees, while the other (by Prof SK Acharya and Govind Makharia) cater to those who have joined their training programs and have 2-3 years of fellowship ahead.

It was estimated that around 100 trainees would be taking their exit exams every year; hence 2 courses were planned every year ( with around 50 candidates each), one to cater to trainees in the northern and western parts of India, and the other to cater to trainees from southern and eastern parts of the country.

This report pertains to the program undertaken for exam going trainees:

Background:

1. Number of trainees in Gastroenterology in India: on the increase

2. Upsurge in the number of centres offering DM/ DNB courses in the last few years

3. Need to improve & homogenise the training programs in Gastroenterology in India

4. Wide variation in results in DM and DNB examinations, from different centers in the country, reflecting varied levels in different components of training.

5. Formation of the Education Committee in ISG in 2007 with Dr S K Acharya as its Chairman

6. Dr Acharya’s presidential address in 2006 covered the need for modifying and updating the training and curriculum in Gastroenterology in India

Overview and objectives:

To supplement the basic academic training of DM/ DNB students through an annual short preparatory course conducted under the aegis of ISG with faculty comprising leading educators / potential examiners

Specifically:

1. Expose exam-going trainees to the examination format (case presentations) with potential examiners, so that examinees know what to expect and familiarize them with the type and manner of questions usually asked by examiners in DM and DNB examinations.

2. Pool and share expertise from faculty drawn from various centers

3. Provide guidance on other exam survival tools such as radiology and pathology spotters, tips on clinical examination, theory etc

4. Attempt to bring about homogeneity and uniform approach of examiners by sharing the same platform and facing the trainees.

Format:

• Annual update for 2 days

• Residential program at a neutral non-academic venue well connected to major centres

• Targeted at Senior GI trainees (2nd yr/ 3rd yr DM & DNB students) especially those preparing for final exam

• Two separate venues for geographical convenience & for optimum no of participants

• North & West in one venue and South & East in another

Course content:

• Course content primarily includeed topics that would aid preparation for final exam

• Similar to a pre-board/ pre MRCP training

• Live cases : 3-4 (Luminal, Liver, etc)

• Radiology : Basics & Advanced imaging

• Pathology Spotters

• Endoscopy/ Instruments

• Tips for Exam preparation

• Milestone Articles

• New Drugs

Faculty and Facilitators:

• Program Director : central co-ordinator to ensure overall continuity, improvement & achievement of the program objectives on a yearly basis

• Course Director : Incharge of one program : coordination & delivery especially arranging and transporting cases to the venue, and making all investigation details available to trainees; two Course Directors every year

• Faculty members : Leading Teachers/ Potential examiners & Senior Clinicians; primarily drawn from institutes offering DM/ DNB courses

• Core team of around 10 faculty to remain constant while others on rotation

The 1st steps:
• Proposal approved in General Council meeting – Delhi (APDW), Sep 08

• Drafting of initial program by Program Director.

• Communication to ISG (Chairman of Education Committee, Hon Secretary & President of ISG)

• Selection of Course Director/ Local Coordinators based on local requirements and logistics

• Letter from Program/Course Directors to faculty members & HODs for enlisting trainees

• Logistics : Venue arrangements, travel, stationery, momento etc by industry sponsor (Sun Pharma)
Course name and logo:

The First program was a new experience. Its details are as follows:

• Period : 27th Feb to 1st March (Friday evening to Sunday afternoon)

• Venue : The Atria, Surajkund near Delhi

• Course Director : Dr Vineet Ahuja (AIIMS)

• Trainees from North & West

• No of participants : 55

• No of Faculty : 32

Although the original plan was to have around 15 teachers, many senior faculty members from centers that run training programs expressed their keenness to attend the 1st course to observe and judge its utility for their trainees. Hence, the number doubled and almost all training centers had their faculty attending the session.

Faculty list:

  GYM Delhi : List of Faculty

The 2^nd session catered to trainees from South & East

•          Period : 26^th to 28^th June (Friday evening to Sunday afternoon)

•          Venue : Chariot Resort, Mahabalipuram, Chennai

•          Course Director : Dr K R Palaniswamy

•          No of participants :47

•          No of Faculty : 32

As most of the training centers and trainees were from the southern region, a proportionate larger representation from the region reflected in the constitution of the faculty.

Faculty List, GYM Chennai : 

Feedback

A special effort was made to collect feedback from the participants and analyse them, to assess how the program was received and to modify it in tune with the requirements /suggestions made by the trainees.

Feedback from GYM Delhi.

Feedback from GYM Delhi - 2

Feedback from Chennai -1

It was felt that the session on “Statistical Methods: Concepts”, (that featured in the 1^st GYM session in Delhi) would be more valuable to trainees joing the DM/DNB program than just before the exit examination.. This issue was discussed with organizers of the PG course for 1^st year DM/DNB trainees (Young Clinicians’ Program) and a session on Statistics therefore featured prominently in the meeting held in Agra. Hence, this session was dropped for the next GYM session (catering to exam-going trainees) in Chennai

The map below depicts the centers that offer training in Gastroenterology in India, and from where the participants and faculty were largely drawn. There was good match between them.

Feedback

•          Overall feedback from students/ faculty : good

•          Rating from students : mostly good or excellent

•          The opportunity of meeting potential examiners was also found very useful

•          Many trainees felt that the timing of the program could be advanced toFeb/Mar/Apr (before the DM/ DNB exams)

•          They suggested more case discussions to be included

•          Limit faculty to around 15 per program (some constant, some by rotation). The faculty should be willing to spend the entire duration of the course at the venue and thus spend more time interacting with trainees.

•           Continue neutral venue outside institutes

The program seemed to have been highly appreciated by the target group, ie trainees, and has made a good and impactful beginning. The challenge is to keep it useful and interesting for trainees and involve other teachers by rotation as well.