Doc At Party

My well-wishers and grateful ex-patients wonder why I fail to turn up at their parties despite their pleasand insistent invitations. While my wife usually gets fed up with the adulation and importance I usually get from satisfied patients or their relatives at parties, some sour ones are educative enough.

I once found myself squeezed between two defence officers at a party at the MB Club. They seemed jovial, friendly and in “high spirits” and had many interesting stories to tell. Their demeanour however changed  once they learnt that I was a doctor at the SGPGI. The conversation then turned to how terrible places hospitals were, how uncaring the staffs were and how one of them had lost a relative at SGPGI after a heart surgery due to, what they perceived, neglect. 

My feeble protests that I belonged to a different speciality , that patients sometimes do die after heart surgeries in spite of the best treatment, just as jawans do in a war despite all armours, and that the utterance of one rude nurse should not denigarte a whole hospital, fell on deaf ears. When he ordered his 3^rd “Patialla peg”, I realized that it was time to move to a friendlier (or less hostile) table.

The other demand that we face in parties is of medical consultations. When a stranger flashes a smile and moves close with his drink in hand and I reciprocate eagerly hoping to strike a new good friendship, the discover the motive is often quite different. . After the preliminary pleasantries he often dives staright into his irregular bowels, his children’s adenoids or his father’s enlarged prostate, asking for my cell number and that of my colleagues, seeks  an assurance that I will help him circumvent the tedious lines at SGPGI, and a guarantee that all will turn out well when he does!

In another party, I found my industrialist  friend’s wife proudly displaying a painting that she had picked up at Sotheby’s. A beaurocrat guest, not to be left behind, jumped into the fray with his story of buying an art piece at a London auction house (you are not supposed to ask in a party how he acquired such money!). And that is how the converstaion went, till he discovered that I was a doctor at SGPGI, when it turned to hospital bashing, discussion on the terrible state of medical ethics, the lack of facilities at government clinics and so on. When I thought I had had enough, I mustered up the courage to ask him if he had ever been a secretary in the health department. His flushed face indicated that he had. I then let the next obvious question dangle “What, sir, did you do to improve the state of these terrible government hospitals when you were in power?”  That party ended on a sombre note.

It is little surprise then that doctors mingle more amongst themselves and shy away from “mixed parties”

 As published in HT City ( Hindustan Times) dated 28 november , 2010.

Taking The Sting Out Of Bad News

While the news may be bad, the manner in which it is delivered can make it either traumatic or bearable, says Dr Elly Hann, an expert on end-of-life care programme.  And what is interesting is that the technique applies not just to patients detected to have cancers, but to any bad news like loss of a job, failure in an examination, or a failed relationship,

It is being increasingly realized that bad news, no matter how bad, needs to be told rather than concealed, as getting to know it helps the patient or victim to cope better and set realistic goals. Recent research contradicts traditional belief that it takes away hope plunging people in irretrievable despair. That is of course if the news is communicated properly.

The currently accepted technique of delivering bad news that we might all find universally useful in our own lives, has 6 steps.

Step1: Getting started. A little thoughtful preparation needs to go into ascertaining and reconfirming the unpleasant facts before telling them and in creating the right environment, ensuring adequate time and deciding who else needs to be in the room. Breaking bad news, such as the test report showing cancer, cannot be done with frequent interruptions by cell-phone calls, or in a crowded room,  or in haste as while rushing to work on the corridor. You would realize that similar factors would apply while you tell your son about his poor results in an examination or discuss a breakup with your romantic partner.

Step 2: In this step one explores what is already known. The patient may be aware of the diagnosis and may be seeking a validation.

Step 3: is finding out how much the patient wants to know. In Asian cultures, an elderly woman may not want to know the diagnosis, and may delegate the responsibility to her eldest son to find out and decide further. Her wish needs to be respected.

Step 4: is the actual sharing of the information. It should be straight-forward but delivered with sensitivity. It is useful to give a few warning shots such as “The results have come. I am afraid the news is not good” or “I have something serious to discuss with you, unfortunately it is not good news” . Then the news needs to be stated, briefly, clearly and unemotionally. Then WAIT. Let it sink in and let the patient emotionally process the information. Non-verbal communication, such as putting your hand on his shoulder, is of more value at this stage than a long flow of words which the patient may have stopped listening to. Start speaking only when he has responded.

Step 5: is to respond to the feelings that the bad news generates; it can range from depression, anger, and guilt. One needs to be a good listener at this stage, allowing the patients verbal emotions to flow.

Step 6: is to offer follow up and to reassure non-abandonmnent. Break up of a relationship can be hurting, but to decide to part on pleasant terms without animosity or hostility, and remain in touch as friends, will ensure a smoother life ahead for both.

Let us try to take the sting out of bad news in our clinics, homes and offices.

 As published in HT City (Hindustan Times) dated 21 november , 2010.

Test Tube Baby Finally Gets The Nobel Nod!!!

The 85 year old British scientist, Professor Robert Edwards, who helped create the first test tube baby and thus transformed the lives of millions of couples plagued by infertility, was finally awarded the Nobel Prize for medicine, 2010. The person happiest to hear the news was Louise Brown, now 32, who on July 25, 1978, became the first ever child born through in-vitro fertilization (IVF), to her mother Lesley, who was seeking tretament for infertility.

Professor Edwards along with his research partner Dr PatrickSteptoe, had been resarching on taking eggs out of a woman’s body after stimulating the ovary, and fertilizing it with sperms from a donor, in a petri dsh, allowing it to multiply a few times, and then putting it back into the womb of the woman. Their first success came with Lesley Brown who gave birth to Louise by natural delivery.

Dr Steptoe, with whom Dr Edwards had started his infertility research and clinic in Cambridge, died in 1988. As the Nobel Prize is not awarded posthumously, Dr Steptoe could not receive it, leaving many across the world feeling that the recognition for the scientific work should have been much earlier.

The “test tube” often causes confusion. “I was never inside a test tube nor could I get in to one if I tried” says Louise. Only the fertilization of the egg is done in the laborartory, the subsequent growth of the baby in the mother’s womb occurs as in normal pregnancy.

Infertility is a common problem with 10% couples being unable to conceive naturally.  IVF has come as a boon for them. Although still costly and with a 25% chance of success, it has changed many lives across the world. Around four million children have been born by IVF till date and many like Louise, have gone on to get married and have children by the natural way.

India has had its brush with IVF too. A Bengali doctor Subhash Mukhopadhyay was two months late in announcing the birth of Durga or Kanupriya Agarwal - India’s first test tube baby created by him on October 3, 1978. While Edwards, was lauded for his effortsin UK, Mukhopadhyay was fighting a hostile state government that rubbished his findings. Ridiculed and ostracised, Mukhopadhyay was also not allowed to publicise his work in the international arena.He was invited by the Kyoto University in 1979 to present his findings during a seminar in Japan but denied a passport by the Indian government. The depressed physician committed suicide in 1981.

 The Catholic Church has been vehement in its opposition to reproductive research and IVF terming it “duhamizing”.  IVF does pose potential ethical problems as that of a Spanish woman who conceived and delivered at 67 and died 2 years later. Also it is possible for a child now to have 5 parents: the egg donor, the sperm donor, the surrogate mother in whose womb the foetus grows, and parents who rear the child, posing serious issues of parental rights and responsibilities.

 As published in HT City ( Hindustan Times) dated 14 november , 2010.

Smokers now have Help

A new medication, varenicline, promises to help smokers who are keen on quitting the habit, to do so with ease and comfort.

Quitting smoking can be hard for smokers as nicotine, the substance in tobacco that gets you hooked, is one of the most addictive substances known to man.  Stopping suddenly is sometimes associated with intense craving, mood swings, abnormal behaviour and depression making smokers continue with their habit indefinitely till a major health event like heart attack or cancer shakes them out of it.

The addictive effect of smoking is due to nicotine that gets attached to a site in the brain called alpha-4-B-2 receptor and triggers neurochemical pathways that provide the sense of pleasure that go with it. Varenicline works by geting attached to the same site in the brain, thereby blocking nicotine from getting to it. Why Varencline particularly seems to work is because apart from blocking nicotine, it exerts a mild stimulatory effect of its own, just enough to prevent symptoms of craving and withdrawal, but not strong enough to serve as a nicotine replacement.

The beneficial effects of Varenicline have been proven in studies involving more than 4000 smokers who were given either the drug or a placebo (non-active similar looking pill) in a blinded manner, with quitting rates being 3 times higher in those getting the drug.

Manufacturers recommend a slow build-up with 0.5 mg of the drug once and then twice daily for a week, and then to the normal dose of 1.0 mg twice a day for 12 weeks. The “muhurat” or “target quit date” should be around the 7^th to 10^th day. The 11 weeks of therapy that follows provides the transition to a “smoke free” life. The drug is expensive, therapy costing around Rs 7000/-., but one could argue that it is less than the cost of cigarettes and the health bills due to smoking . Never the less it is an additional burden for a well meaning puffer who seems to have recently acquired good sense and intention to transform himself.

Does it work with those addicted to other forms of tobacco such as Gutka? It should, theoretically, but direct hard proof from research studies of its usefulness in Indian Gutka chewers is lacking.

Of equal concern is that all those who take the drug do not succeed in quitting tobacco. The answer here is easy though. Without adeqaute motivation and will power, no drug or strategy ever works. As they say, “You can take a horse to the water but can’t make it drink”. If you seriously wish to quit, you surely can. 

As published in HT City ( Hindustan  Times ) dated 7 november , 2010.