Monday, June 30, 2008
She was working in a Government run rural pre-school centre. Her 4 year old son [who was always sick] was diagnosed to have AIDS. He succumbed to his disease.Both she and her husband were tested 'positive'.The news got around and the parents of the kids under her care and even some of her co-workers began whispering. Finally they told her not to come for her job.
The District Health authorities intervened and tried to pacify the parents.After few months She went back to work but still had to face lot of problems. So she stopped going though
she continued to be employed there officially.
Now she is sick and came to see me.She first saw me few months ago at the Positive Network's office where I was there for my health class. There she saw me sharing food with the 'positives'.So she had confidence in me.As soon as she settled in her chair in my room she revealed that she is 'positive'.Then she told her story.
Her immunity was low for quite some time and she should have started ART[Anti HIV treatment] a year ago. But psychologically down due to her troubles in her work place she did not go to the ART centre.
She was really ill,most probably suffering from multiple infections due to her low immunity. She wanted some immediate relief but again refused to go to ART Centre. After listening to her whole story I talked to her explaining that there is no short cuts.She will get relief only if she start the correct treatment. I reassured her that there wont be any discrimination at the ART centre. At the end she promised me she will go and get the treatment.
I hope she will.Otherwise I don't think she can survive another year.
Friday, June 27, 2008
You may think the main reason is fear of getting the infection.But there are other serious infectious diseases which are much more easily transmitted to health care workers like Hepatitis B, Hepatitis C and Open Tuberculosis.Patients suffering from these diseases are usually not stigmatised or discriminated. Then why against HIV/AIDS?
This website summarises the reasons well.If you have any views or comment please be free to express it here.
Thursday, June 26, 2008
Why do they hide the 'positive' status?Especially why do they hide in front of that doctor?
None of them hide their 'positive' status from me.Because they knew from their friends or relatives or other doctors that I never discriminate. So why they hide their status elsewhere? Because they fear stigma and discrimination. They know that the moment the 'positive' status is known they will be discriminated and stigmatised.If there is so much stigma and discrimination among medical community what can you expect from common people?
Tuesday, June 24, 2008
Unfortunately it is widely available in India. As it attains good concentration in urine and eyes it is still widely prescribed by Ophthalmologists and Urologists.Lack of awareness among doctors about Gatifloxacin's above mentioned adverse effects reflects the sad state of drug information system in India.The situation is made worse by laboratory culture reports which show sensitivity of the organism only to one oral drug,Gatifloxacin.
I had some bad experiences with this drug.Many of my diabetic patients went in to either Hypoglycemic[low sugar] coma or dangerous hyperglycemia[high blood sugar] after taking Gatifloxacin prescribed by other doctors.
It is high time for the Drug Controller in India to either ban or display black box warnings on the label of Gatifloxacin so that no further harm is caused to the patients.
Monday, June 23, 2008
Imagine you are referred by your family doctor to a consultant for expert evaluation.
1.Before leaving your family doctor's consulting room, make sure that you have a referral letter to be taken to the consultant. Also ask your family doctor to tell roughly how much expensive the consultation and relevant investigations will be so that you can be prepared.
2.Try to get the contact information of the consultant's clinic. Ring up and fix an appointment.
3.Take all your past medical records with you, even those you think is not relevant.
4.Write down all the problems you face in a paper so that you will not forget anything.
5. Try to tell the consultant your symptoms in the order at which each appeared[chronologically]
6.Don't forget to mention any drug intolerance or allergies you have.
7.After the examination is over, listen carefully to what the doctor have to say about your illness.
8.If he/she is not forthcoming with an opinion ask directly, ' what do you think is wrong with me?'
9.If asked to do investigations, ask when and where to do and when to come back with the results.
10.If a prescription is given, you can ask how long it will take for the symptoms to get better and when to come for review
11.Ask for an emergency contact number at the clinic or the hospital.
12. Get back to your family doctor and give an account of what happened.
If you do all this, you can be assured that you had made maximum out of the expert consultation.
Sunday, June 22, 2008
She is 31 year old newly wed, wife of a factory worker. She was diagnosed to have Diabetes 7 months ago. The prescription she got from a Government run hospital was for Insulin, and she pricks herself twice a day for last 7 months. Her blood sugars were still high. Someone might have suggested my name. Thus, she turned up in my clinic.
When I asked her family history, I was surprised to hear that 2 of her sisters and one of her brother were Diabetic. That meant she most probably had Type 2 Diabetes which occurs in family, in contrast to Type 1 where family members are not usually that much affected. Type 2 Diabetes is mostly due to Insulin resistance [Insulin is there but not working efficiently]. Initially it is treated with oral tablets which improves Insulin efficiency, but she was prescribed for Insulin which is clearly not helping to reduce the blood sugars. Why?
Her story was like this. As she had very high blood sugars at the time of detection, she was given both tablets and Insulin injections. After controlling her blood sugar, her doctor asked her to continue on tablets. The tablet that was prescribed was not available in the Govt pharmacy, on the other hand Insulin was available free of cost. She comes from a poor family and is recently married to a lowly payed factory worker. She did not want to burden her new family. So, she opted for Insulin which she thought was the superior treatment.
I explained to her that, for her tablets are better option.I assured her that I can reduce her blood sugars with cheap tablets available in the market. Somehow I was able to make her understand that the 'free Insulin' [which is expensive in open market] is not good for her.
Still there was a problem. She already had 3 vials of Insulin with her and she did not want to waste it. So, we reached a compromise. I asked her to continue Insulin at a reduced dose, but started her on oral medicine for better control of sugars. I am sure when she come for follow up visit her sugars will be much lower.
In India[may be everywhere else also] it is tough to be poor especially, if ill.
Saturday, June 21, 2008
I hear this question from my patients over and over again.It is asked when you give a prescription for a medicine to be used for a long time or even indefinitely. Medicines given for controlling blood sugar in Diabetes and those given for controlling Blood Pressure in Hypertensive patients etc receive such question.
Many believe that once such medicines are started the patient get addicted to it and will never be able to stop it because of that.Is there any addiction potential for such medicines? Not at all. Then why such belief?
These medicines are usually started after trying out non-pharmacological methods to control blood sugar and blood pressure.Non-pharmacological methods include changes in diet and life style,exercise regimens and measures to reduce stress.Reduction in body weight will also help a great deal.If the sugar value or the blood pressure do not get controlled by these methods medicines will be prescribed.As Diabetes and Hypertension are not curable but only controllable, most patients have to take the medicines indefinitely.
So what is the answer for my patient's question?
Most probably you cant stop the medicine,unless a profound change in lifestyle, diet, body weight etc bring the sugar and blood pressure values to acceptable levels with out medicines.
And what happens when you suddenly stop the medicine on your own? May be nothing for few days.Your blood pressure or your blood sugar starts rising steadily to your pretreatment level or even more. Over a time an elevated blood sugar or blood pressure causes damages to your body.Thus stopping the medicines will definitely have deleterious effect on your health.
So better not to stop such medicines on your own.
Thursday, June 19, 2008
But some patients I like very much.It is always a pleasure to talk to them and take care of them.Why?Let me tell you the reasons.
I like a patient
1.who will come to see me only with a proper appointment and will do otherwise only in case of a real emergency
2.who will come with all his relevant medical records for me to pursue
3.who will tell me all his symptoms in a chronological order[may even come writing it down] so that I can get a clear picture
4.who will try to clear all his doubts regarding the diagnosis,tests to be done and the medicines to be taken then itself
5.who will not come back with a new symptom[which is actually present for years] after reaching the door on the way out
6.who will not make me spend a lot of time on telephone as a follow up to the consultation.
7.who will keep his review appointment and come back with all the tests I ordered
8.who will inform me why if he /she could not keep the review appointment
9.who takes all the medicines in proper dosage and for the proper duration[if not will inform me and not lie]
10.who if not better with the medicines will tell me that in a nice way so that I do not feel bad.
May be I can go on and on like that. Most doctors may feel similarly.So next time you visit a doctor you will know what he likes and dislikes. It may help in you getting prompt diagnosis and better treatment.
Tuesday, June 17, 2008
Why should I dislike a patient? Let me think.......
These are some of the reasons for disliking a patient.
I dislike a patient
1.who walks in [as if going to a movie] leaving his previous medical records safe at home making me do all the guessing about his previous illnesses
2.who gives you the diagnosis himself/herself [see my blog entry 'self diagnosis']
3.who talks ill of his/her previous doctor imagining that it will gain my good will.
4.who fakes the severity of his/her illness to jump the Que at my clinic
5.the one that never take the medicines as prescribed explaining that his/her neighbour[or a friend?] had told that it is over dose.
6.the one who refill the prescription [containing medicines which should not be used long term] again and again with out consultation
7.the one who never take pains to come to the clinic but rely on telephonic consultation.
8.the one who never do the tests I ordered but just want prescription for medicines.
9.the one who falsely blame me for not keeping the date of followup appointment [saying falsely I was away on that date or the Clinic telephone was down].
10.the one who had come for his wife's illness but want me to check his blood pressure and give some free advise regarding which Blood Pressure medicine is the best.
Now please tell me the reasons for disliking a doctor by a patient.
Monday, June 16, 2008
I get several such patients.Most of them are thin built girls in their late teens or 20s.When I ask them about their symptoms most of them have occasional dizziness,fatigue and tendency to vomit.Most often it is after a tiring day at school or college. They get better after eating something or resting after some time.
When I checked her BP it was 100 systolic and 64 diastolic.She did not had any symptoms then.Her mother is taking medicines for high blood pressure.
Low pressure as a diagnosis in healthy adults is a myth. Normal blood pressure is usually defined as systolic BP below 120 and diastolic BP below 80. The lower limit is never specified. A low blood pressure in otherwise healthy individual can be considered as sign of cardiovascular well being. See this site for a detailed information.
Then how come this myth is so popular? Many people including health care workers and medical professionals has an erroneous belief that normal blood pressure should be 120/80.
Also it is easy to blame the blood pressure for the vague symptoms.Most of the symptoms attributed to low blood pressure is due to positional vertigo,migraine or Anemia.
Is there any harm in this belief?Obviously there is.I had seen many women in their 40s and 50s when told that they have high blood pressure express surprise.They had always been told that their Blood pressure is low and was advised to eat more salt. Most probably this increased salt in their diet might have precipitated Hypertension[High Blood Pressure] as their age advanced.
So here after if somebody tells you an out patient diagnosis that you are suffering from 'low blood pressure' take it with a pinch of salt.[Actually I meant no excess salt]
Sunday, June 15, 2008
When I reached there, the meeting had already begun. It was held in a Hall in a house which also houses the office of the network. There were around 50 adults, women almost equalling men. Around 10 kids were also there playing in the next room.Most women were sitting on the floor while men had chairs and few benches to sit. Most of them were poor, some may be in lower middle class. Most are Hindus, some Muslims and a few Christians. They include Manual labourers, Drivers, House wives, Sex workers and many are currently unemployed. The only thing common about them was that they were all 'positive' persons.
Today was their monthly meeting day. They come here to discuss their health, about Stigma and discrimination they face, about the difficulties they face in getting employment and sending their kids to school, and about the ways to get more benefits from the Government etc.
When I came in their faces lit up. I know many of them. I am a regular visitor there. I usually take Health classes for them. I give them hope and so they like me.
Today also I stressed the importance of taking medicines regularly in the correct dosage at the correct time. I told them not to worry about side-effects of medicines. It can be managed. I told them the importance of healthy food and asked them to abstain from tobacco and alcohol.
They listened intently and in the end when I asked if they have any questions, many stood up but they were not asking questions. They wanted to consult me. They wanted solutions for their personal health problems, not a health lecture. Such lectures they are hearing regularly.
I saw some of them. A 10 year old kid taking ART [ anti retro viral therapy] had Scabies. A 45- year- old man's cough was persisting even after completing anti tuberculous therapy. Many had general medical complaints not related to their 'positive' status. They were not keen on relieving their status to other doctors. They also complained that when they reveal their 'positive' status, many doctors ask them to get treatment from the ART Centre [which is 2 hours away]itself.
I did not had time to see all of them as I had planned only a class. The organisers were embarrassed.They started shooing away those crowding around me. I went promising to come again to them another day.
The Government and many NGOs are helping them.Even then their plight is miserable. It is a big fight for them every day to keep their body and soul in good spirits.I try to do my bit by being positive with 'Positives'.
Saturday, June 14, 2008
Unlike last year I see only few patients with Chikungunya fever. Most doctors and even patients are familiar with the disease. So many are getting treated at local dispensary itself.
Chikungunya fever is easily diagnosed in many patients. They will have high fever with chills and shivering of sudden onset. Joint pains with swelling is characteristic especially on the small joints of hand. Fever last for 2 to 4 days only but is usually followed by itchy skin rash.
The joint pains may persist for many weeks and in some persons up to an year.
Only in the elderly patients who are already sick with various other ailments that Chikungunya can be lethal. They have to hospitalised and closely monitored. Treatment is mainly supportive and death is rare.
Dengue fever and Rat fever [Leptospirosis] are more difficult to diagnose and treat. Fortunately both are not so common.
Friday, June 13, 2008
Pushpa Bhargava in an interesting article in 'The Hindu' is of the opinion that it was destined to fail. Many of the experts as early as in 1988 were favouring Injectable inactivated Polio Vaccine[IPV] for achieving eradication.
Many investigations show that while in developed countries three doses of IPV or OPV can produce a protection rate of 98 percent, in developing countries it was consistently found that OPV is much less effective than IPV. Two doses of IPV can generate a protection rate of 89 percent, while the protection rate of two doses of OPV is only 72 percent. Three doses of IPV can protect almost 100 percent of the children, while three doses of OPV protect less than 85 percent of the children The reasons for the difference in OPV efficacy in developed and developing countries are not clear. Problems with the cold chain explain only a small part of the difference. The major reason might be the interference of other virus infection, e.g., diarrhea caused by viruses, which hinders the uptake of OPV.
Then why the Government went along with WHO in choosing OPV for eradication?
Wednesday, June 11, 2008
I take pride in my ability to make my patients quit smoking.In last 10 years I might have helped hundreds of my patients quit smoking.
First I tell them that there is a long Que of diseases trying to get into the body of a smoker.Who will come first I don't know. It is a race. Either heart attack or Lung Cancer or mouth cancer or chronic obstructive lung disease or one of the umpteen other diseases and cancers will win the race but others will soon follow.
Then the patient will respond by saying "I will reduce smoking".
"That is of no use. That wont save you from those diseases " will be my warning.
Then the patient will say "I will reduce first and stop completely within a short period".
My reply will be "In my experience it is difficult to stop smoking like that. The best method is to stop suddenly. I am sure you will be able to stop suddenly when you are in ICU but it is wiser to stop it before reaching the ICU". The patient will be usually convinced.
Then in the patient's file under that day's date, in bold capital letters I will write STOPPED SMOKING TODAY and show the patient what I had written. This works most of the time.
For very heavy smokers quitting suddenly may not be that easy, but still with some mental strength most people can quit suddenly.
These are the immediate and long term benefits of quitting smoking from cancer.org
20 minutes after quitting: Your heart rate and blood pressure drops.
12 hours after quitting: The carbon monoxide level in your blood drops to normal
2 weeks to 3 months after quitting: Your circulation improves and your lung function increases.
1 to 9 months after quitting: Coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection.
1 year after quitting: The excess risk of coronary heart disease is half that of a smoker's
5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.
10 years after quitting: The lung cancer death rate is about half that of a continuing smoker's. The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease.
15 years after quitting: The risk of coronary heart disease is that of a non-smoker's
Kicking the tobacco habit offers some benefits that you'll notice right away and some that will develop over time. These rewards can improve your day-to-day life a great deal.
your breath smells better
stained teeth get whiter
bad smelling clothes and hair go away
your yellow fingers and fingernails disappear
food tastes better
your sense of smell returns to normal
everyday activities no longer leave you out of breath (for example, climbing stairs or light housework).
Tuesday, June 10, 2008
1. Lack of time for the patient [or his care taker} to attend the Clinic/Hospital
2. Availability of all most all medicines in the local pharmacy with out a prescription
3. To save the doctor's fee
4. Belief that comes from ignorance that there is no harm in self medication
5.Unavailability of doctor appointment or many a time in rural areas lack of doctors
All these contribute to the spiralling increase in market share for Over the Counter[OTC] medicines. In India it's share is almost 30 percent of the total Pharma market.Many of the drugs which are sold without prescription are not really approved as OTC product. Sale of non OTC products over the counter presents grave health hazard to the patient.What is the solution?
Monday, June 9, 2008
She is a Diabetic patient for the last 5 years and according to her the blood sugars were always high what ever tablets she used. Her husband was my patient for the last one year and for him I had started Insulin injections as his blood sugars were not controlled with tablets.With Insulin his Sugar values rapidly came to normal levels and his quality of life also improved.Seeing the improvement in her husband this lady on her own started taking her husband's Insulin one month ago.She was coming to me as a patient for the first time.And today she came to me with perfect blood sugar levels.
She said she feels much better now and asked whether she can continue on Insulin? What could I say?
Recently one of my patient,a 60 year old woman was admitted for blurred vision and giddiness on standing up. She was on regular medications for high blood pressure and this time on admission her blood pressure was very low. She said she had severe headache from morning.She thought it was because of high blood pressure and so she took an additional dose of her blood pressure reducing medicine.This self medication resulted in blurred vision and giddiness due to low blood pressure.
Tendency to continue taking medicines that produced immediate relief is very common.Most of the pharmacies in India give refills for old prescription with out any question.
Pain Killers are usually abused like that.Excessive use can produce Kidney and Liver damage.
One of my patient was using one such drug everyday for 20 years and she finally landed up with chronic kidney failure. Oral Steroid tablets are very popular among asthmatics and is easily available and cheap.Continuous use of Steroids can result in thinning of bones,Diabetes,recurrent infections etc.
Why people continue this dangerous habit of self medication?Is it just ignorance?
Saturday, June 7, 2008
' From yesterday morning my Spondylosis began troubling me.It started at the base of the neck and then spread up to all nerves in my brain.From evening onwards it was my Sinusitis with unbearable pain around my eyes. Today morning I was better as I slept with out a pillow. But by afternoon because of my new glasses [ which I began using one month ago] I had dimness of vision and watering of eyes. As I felt bad I took a pain killer which produced 'Gas' in my stomach and I had to vomit.
Many patients describe their illness like that.They will have all the diagnosis ready.They are so sure of the reason for their illness that sometimes I feel why they had come to me.May be just to confirm the diagnosis? Or to show off their medical knowledge?
With such patients it is very difficult to get a true account of his/her symptoms.A patient should try to tell the doctor what symptoms he/she felt, the order of occurrence of symptoms[chronology],what triggered/aggravated and what relieved the symptoms etc.It is better not to tell what he/she think is the cause of the illness unless asked to by the doctor.Let the doctor reach his/her own conclusion.
If the patient already come with a diagnosis of his own,there is a strong tendency among doctors to come to the same conclusion which many a time may be incorrect.Especially it happens with less experienced doctors working in Emergency Department. Several times I had seen the diagnosis given by the patient written down in the case sheet from the emergency department overlooking glaring clinical evidence to the contrary.This sometimes result in delay in diagnosis and unnecessary medications.
Ideally the above described patient should have told me about her symptoms like this.
'Yesterday morning I felt pain on the lower part of back of neck which slowly spread up to my forehead.By evening that pain was less but I had severe pain around my eyes.Today morning i felt better,I don't know why.But by afternoon I had some dimness of vision and my eyes started watering along with headache.I took a painkiller but after some minutes I vomited'.
However smart you are, it is always better to leave to the doctor the job of finding the cause of your illness.
Thursday, June 5, 2008
How will this affect Indian Health care system?As per World Bank estimates about 80% of all health spending in India is in the private sector.Most of the Posh private hospitals are out of reach of majority of Indians.They are considered as gleaming Islands of excellence surrounded by seas of medical neglect. So a doubling of medical tourism earnings may only make these Islands of excellence more and more inaccessible to common people.Also more and more of the qualified medical professionals may opt out of Govt run Hospitals for highly paid jobs in private sector.This will further weakens Public Health Care
If the Government [which now spends less than 1 percent of its GDP for health sector] can direct some part of the revenue the Health Industry will earn by medical tourism for strengthening the Public health care network the poor Indians may benefit.But that needs considerable amount of Political will and perseverance.
Wednesday, June 4, 2008
When we see frequently devotees getting sick after pilgrimage to a particular Temple, our suspicions are raised. For last few years, I am seeing devotees getting sick within few days of their travel to Mookambika Temple at Kollur, Karnataka. Many had a severe form of typhoid, some had jaundice due to Viral Hepatitis, and most had an acute self-limiting diarrhoeal disease. Almost all my patient devotees had taken the Temple feast. I strongly suspect either there is fecal contamination of the water used for drinking /cooking, or one of the food handler may be a carrier for such disease causing organism. I had informed this to local Public health authorities, but it seems not much action had been taken as the Temple is in a different State. So now it is wiser to stay away from the temple feast there to maintain the health of our body. Or will the Temple authorities of one of the most famous Devi Temples of India wake up and act?
Monday, June 2, 2008
Last week I started anti tuberculous medicines in 5 patients,3 of them on the same day. I offered them reference to Govt TB control facility.I told them that they will get the drugs free of cost and that the drugs are of good quality.But only one, a poorly paid nursing trainee took the offer.Others were not rich but were ready to spend money from their pocket for the medicines.Why?
Their confidence in approaching the Govt run TB control centre was low.One reason is such centres are notorious for lack of efficiency. Patients may have to go there several times before they get the medicines.Timings of such centres are such that the patient will have to sacrifice few of his/her working days.Also there is stigma associated with queuing up in front of the crowded TB centre.When drugs are available in private pharmacies at a reasonable cost [as there is a Govt control on prices] why should one take all the pains to get those medicines free?
Inefficiency,lack of privacy,unsuitable working hours,ignorance of the public etc are some of the reasons behind the lack of success of TB control programme even in a literate and health conscious,Semi-urban State of Kerala.So we can very well imagine the plight of the programme in other States of India.
Being specialised in Internal Medicine I get lot of referrals of patients with undiagnosed fevers.It is a trying time as in many cases the initial examination and lab tests may not give you a definite diagnosis.And always the patient and /or his relatives want me to say a clear cut cause for the fever at first consultation itself or at least with in a day.
Many of the serology tests become positive only after a few days and the clinician have to depend up on his clinical judgement and experience to come to a possible diagnosis and start treating the patient. For this history of the illness is very important.Most often the patient do not realise it and is not very forthcoming when asked persistent questions about the chronology of the events. Information like whether the fever started as low grade or high grade,whether there was shivering of the whole body at the onset,what other symptoms accompanies the fever etc are very important in arriving at a diagnosis.In many cases the answers to the above questions determine the initial treatment as there may not be any other clue in physical examination.Finding out the correct cause of fever is almost like a detective work.Many clues may be there but some may mislead you to a wrong diagnosis. This challenge of Fever of Unknown origin is one of the most interesting aspect of the professional life of a doctor like me