Interrupt after 17 seconds

Few weeks ago I got a distinct privilege of sitting at a viva station in the exam for first year medical students at our medical school. These are brand new students. Fresh out of 10+2, they have started their arduous journey to become doctors. Enthusiasm is palpable. Their trepidation is apparent: it must have been just few weeks or months that they have been introduced to esoteric terminologies and concepts of medicine. Furthermore, our school places a big emphasis on social responsibility and critical thinking. They must be torn out of their minds in this bewildering world where concepts are being played around them, teasing them, taunting them and daring them. 

I had two questions to ask : one was about communication with patients and another about a concept in patient care. One answer by three of the twenty six students that I talked to intrigued me. They said, "You should interrupt patients after 17 seconds if they keep talking." It did not make a sense to me. But three students are saying the same thing. It has been a while since I last saw one of these History and Physical Examination cook books. Have they come up with new stuff? 

So I decided to pull one out of library shelf and take a look. What they meant was, on an average, physicians interrupt patients after so many seconds. Poor students, who probably have slept only a few hours trying to cover all the bases for next day's exam, got it upside down!

These students are just starting, the mistake is almost cute. But you hope they don't have to go through this confusion in some of the basic stuff of being a doctor. 

These are the kind of things they should be learning by seeing it done. There is no good substitute than the example of deed. Let's talk an example: 

Being a diligent student at the medical school, text book concepts about good patient care was not totally unknown to me. Concepts of empathy, respect did make a sense. But my real education on those issues was seeing the doctors do it. On my first day of residency rotation, a senior neurologist helped an elderly patient take off her socks to do ankle and plantar reflexes. After being done, he put back the socks, helped her with the shoes and walker before she could sit down to talk about her problems. I was taken aback. Does a senior doctor do such things:Take out a person's socks and put them back as if he is a helper in an elderly home? But as the residency days passed, it became obvious that it was a basic courtesy: helping an elderly person. Subsequent days have offered many more occasions to see such deeds that makes me feel privileged.

Our health care system should be able to provide such an opportunity for our students too. A clinical care area where a patient will be treated with dignity and respect will demand the same from a novice student who has all the good intentions of being a superior doctor. Patient care where patient's interests hold supreme will indeed prime the malleable minds of our young doctors to hold up to that standard. Clinical care is where all the real action of education starts, in my opinion. There are no stronger lessons than seeing things being done. Concepts are abstract, they belong to the realm of imagination. We deal with breathing lives, deeds do matter. 

Unfortunately, it is a sad realization, our institutions do not currently have much emphasis on improving patient care. Our educationists are quite fired up when it comes to talking big syndromes in class rooms but when it comes to taking care of small details in patient care (which carry a huge implication for patient outcomes), they are listless, absent and sometimes abhorrent. You will see sleek classrooms in many of these institutions, but they will have crammed up all their patients in a space where breathing is difficult. This needs to change. It is not good. 

Access and Quality

In the 1960s, China saw a phenomenon of "barefoot doctors." Named after barefoot farmers in southern China who worked at the paddy fields in a commune and also practiced medicine, these were farmers who underwent short-term training of three months to a year and delivered basic health services to the community.  This offered decentralized basic health care services which focused on prevention and was sustained locally. 

Despite quite a low per capita income, China achieved infant mortality rates comparable to developed nations by the 1980s. 

Although, there were concomitant social and economic progresses, many people credit improved access to basic health services provided by barefoot doctors for this phenomenal reduction in infant mortality rate. Carl Taylor writes in Reaching Health for All: 

      "The Chinese experience shows that with equitable distribution even the simplest
       and lowest-cost health measures can have great impact. It is more important that
       care at community level be readily available to all with no barriers of cost or 
       social constraints than that it be of the highest quality...."

This should be an illuminating lesson for our policy makers who seem so hung up on coercing doctors to stay in remote areas, as if the presence alone of half-hearted doctors in these desperate places is going to solve all our health woes. This experience suggests that what we actually need is ensuring unimpeded access to basic health services. And this is best provided by locals who receive short-term targeted basic healthcare delivery training. 

While Mr. Taylor emphasizes access over getting obsessed with high quality care at community level, it does not mean that quality of care is a dispensable luxury. As much as our community suffers from access issues, our so called tertiary care centers suffer from quality issues. And, I think, lack of quality in these higher centers is as much of an issue as access is for the communities. 

Few days ago, my father asked if I knew anyone at Tribuhuwan University Teaching Hospital (TUTH). One of my villagers had brought his daughter to the emergency room there and knowing that I was around, he was trying to check with my father if I could put in some words to the doctors in that hospital. First off, I do not know many people at TUTH. Secondly, why should one seek relations when there may be tens of other patients who might be going through the same process of patient care? Still, I half-heartedly called one of my friends at TUTH, just to satisfy my father, and asked him to see if he could ask a resident in the emergency room to check on that particular patient. 

Two days later, when I arrived home in the evening, I found the patient, her father and her cousin camped at my living room. They had left the hospital against medical advise, one of the notorious LAMAs (Left Against Medical Advice). Frustrated, father explained his dissatisfaction thus: 

They were in the emergency room, a place akin to goat shed (in his own words). Nobody seemed to know what was going on with her. Students poked on her eight times drawing tube after tubes of blood as if the sole purpose of her presence was to offer a  practice opportunity for these students. They were told that she needed blood and she needed to be admitted. Somebody told she would need a bone marrow biopsy; another person told she did not. After less than a 1/2 of the first unit of blood was transfused, the catheter clogged and blood was not transfused for several more hours. When asked why the catheter got clogged and blood was not running, they were told an inexperienced person had put in a catheter. So what is the purpose of staying in the hospital, if she is not getting the treatment and is a subject of experimentation every step of the way? That's why we left the hospital. 

I flipped through a sheaf of medical documents. She had gone there with a feeling of weakness and shortness of breath. During evaluation, her hemoglobin was found to be quite low at 6 g/dL (normally it is around 12). All other testings were normal. 

I can imagine of a rich academic discussion that might have happened amongst the doctors participating in her care. A senior doctor must have asked, "What's the cause of isolated anemia with normal WBCs and Platelets?" An apt among the herd of the learners must have purged out a list of differential diagnosis astonishing the less well-read ones. To that list, the senior doctor must have added some sharp criticisms or comments. Everyone must have been quite appeased by such a rigorous academic exercise, ready for a round of momos, tired  by the effort of recalling data that are normally transcribed in the books. 

But what of the patient? 

She left the hospital with hemoglobin of 6 g/dL. This condition is perhaps not acutely life-threatening, but a teenage girl leaving a hospital in critical condition is a big failure of the system. We tend to blame patients for these kind of failures: LAMA is a patient responsibility, what can a doctor do? We say. But if this person was my daughter, I would have done the same. Perhaps piqued by such repetitive lame arguments, Paul Farmer, a doctor of deeds for the neediest, had a simple thing to say about such non-compliant patients: 

      "The only non-compliant people are physicians. If the patient doesn't get better, it's your
       own fault. Fix it." (In: Mountain Beyond Mountains)

Dr. Farmer is talking about a patient who is not getting better despite some efforts and is asking for increased effort. But we are talking about owning some responsibility for at least critical and acute care. 

Barefoot doctors seem like an attractive option for basic healthcare in our communities but it does not justify footless doctors in our higher care centers. More than that, apathetic hospital administration that leaves patient care to the devices of mob dynamics needs to realize that its somnolence is a reason for much agony. 

Image, Event

October of this year, we visited the Norman Rockwell Museum in Stockbridge, Massachusetts. This painting by Howard Pyle gripped my attention. With a sheer force, it thrust my imagination to the horror of the situation. At arm's length, these men are facing each other. Another man of flesh and blood. Horses neighing, alarmed by the clamor, perhaps injured already by whips of terrified master and sharp bayonets of master's enemies. At this proximity, these men perhaps see their enemies' eyes, face. How do they lift their sharp swords or pointed bayonets and shove it into another man's throat or chest or belly? Whoever plants the sword to another's chest must be numb with an overwhelming force. The stabbed one must be terrified as the darkness replaces the light of life. Those who have not yet planted a sword or been stabbed must be scared, terrified, uncertain. This is a feeling of undescribable anguish, horror and terror. 

It is an image that incites an imagination about the event. 

In the past few days, the world has been subjected to an event, that incites an even terrifying image of horror. A young woman in Delhi is lured into a bus along with her boyfriend. Six men assault them with iron rods, rape the girl, and throw them out of the bus stripped naked and unconscious. We learn today that the girl died.  

Who are these men? These six men. How did they decide they will take a bus down the road, lure a woman, rape her, and kill her? What must have happened in that bus? Six lustful evils preying upon a woman. There must have been shrieks, cries, moans. How did these evils' eyes look when they impaled the  helpless woman's belly with an iron rod? This is an image of horror, pure horror. 

Faulty Analysis

Republica had published an editorial regarding failure rates of medical students at Nepal Medical Council (NMC)'s licensing examination. A little irked by shallow analysis I had sent a tad sharp comment online. They decided to give it a space on print edition the next day: 

The licensing exam failure rate of students who went to medical schools in certain countries, namely, China, Russia, is high. I have heard the argument of requiring students planning medical school overseas pass Kathmandu University's medical entrance examination tests, at varied platforms. It might add some safety by helping select qualified individuals, especially if the exam is standardized to test qualities that determine a good doctor (and not just knowledge, as is done now). However, even if this has any significance, it will perhaps be minuscule. The main action will be in what the student gets in her 5 years of medical school. Until we think about assuring a basic minimal quality in those 5 years, any other efforts will be trials with high chances of failure. 

But what we can do immediately is build mechanisms to rehabilitate these individuals who are doing poorly in the licensing exams. For example, we could require anyone who fails twice consecutively to do 2 years of rotating internships at selected academic institutions in Nepal before they can apply for the license. All who fail, either they have done medical school in Nepal or overseas, should be treated the same. This exercise of demonizing students from select countries is a form of bigotry that lumps all grades of students together. It is unfair to diligent students from those places. And it is ultimately going to serve no good. Even these poorly-trained students  have already spent a fortune and ripe youth at these institutions. They are ultimately an asset to health manpower-deprived country. We need to find ways to remedy their deficiencies and give them a proper place where they can  contribute to the care of sick and infirm of this nation.   

A Squatter Settlement

There is a squatter settlement in Maharajgunj, just behind the staff quarter of Institute of Medicine. On my way to and from work, I sometimes take the way through this settlement. There is something about this settlement that gives a positive vibe. 

It is a crowded place. In a narrow strip of sharply inclining land, it is a motley of shanty houses and few sturdier ones separated by tight alleys. A loud whisper is perhaps audible to the settler's neighbor. Wandering chickens and ducks in these alleys, I am sure, find treats at several of the owner's neighbors. 

But this settlement seems cool about the sardined living conditions. In these narrow empty spaces, which are neatly stone-paved, children are jovially playing badminton and hoola hoops. Adult males are engrossed in several groups of carrom board games, back from work and winding down or unemployed and killing time, I do not know. 

Furthermore, the organization of the limited space is quite impressive. All the alleys are paved with concrete. In the slope, there are neat concrete steps in the alleys gyrating down the hill. At the bottom of the settlement, there is a remnant of river, which now flows with sewage composed primarily of  nearby city dwellers' excrement. They have managed to cover the river completely with concrete structure so that the filth is hidden. The only evidence of that horror is the open river, just before the squatter settlement starts. This open disgust snakes up the non-squatters settlement, malodorous and ugly. It seems like no one cares in those turfs. 

 

Compared to the non-squatters, somehow, these people appear to have been able to do something of common good. It is obvious that they have been able to organize things around them. These narrow alleys are clean, they have common space to play, a big water tank with a tap stands upright at about the center of the settlement that everyone can come to collect water, a filthy open sewage is covered throughout the settlement. 

How have they been able to do it? Did some donor do it for them? I doubt it. Are they unified by common predicament that is driving them to work together for common good? Are they unified at all? If so, what is bringing them together? It does look like development. And what does it tell about our constant whining about the lack of funds for development in our communities?

These are some of the questions which a physician who deals with rotten/rotting/degenerating/broken body is perhaps ill-equipped to answer. But the distinction from indifferent settlements surrounding this squatter settlement can not escape his attention. 

Empiric Treatment

She came with her father-in-law. Wasted and pale, she looked withdrawn, dejected, and lethargic. They were from a village in Kavrepalanchowk. Her husband was away for a labor job in a Gulf country. For the past several months, she was having fevers, poor appetite. As it became disabling, she came to our hospital and was admitted for evaluation. Her fevers persisted. The only clue to her disease was the finding of an enlarged spleen. But several diseases can cause enlarged spleen. Even after several days of hospital stay, multitudes of non-invasive and invasive tests, a cause could not be pinpointed. So our hospital team decided to discharge her from the hospital and have the results followed-up as outpatient.

As outpatient, she had several more visits and a battery of additional tests. Her fevers persisted. On this visit, they came with the results of all these tests. I went through each of these tests. They were essentially normal, one after another. I told them that these tests did not tell us what was making her febrile.

At this stage, her father-in-law entered the pleading mode. Help us, please. We have exhausted our money in quest for the cause of the fever. Almost 40,000 rupees have been spent so far. We have been staying in a hotel to have these tests done and fevers haven't budged. We can not afford to stay longer. What are we to do?

Fever is not an endocrinologist's forte. On top of that, one trained in North America. In these shores, where shit infuses drinking water, cattle and humans share abode, almost infinite souls share a crammed room breathing each other's exhaled air, flies cruise feces and foods, mosquitoes camp between man and animals, weirdest of the bugs can cause weirdest of the fevers. A specific diagnosis is a mammoth challenge. Furthermore, my patient is in desperate financial predicament. Any further testing would be adding salt to their sores. What am I to do?

Many of my patients who come with fever also have tight purses, limiting exhaustive investigations. In desperate attempt to deal with these fevers, I have developed my own way of looking at fevers. The way I see it is, what treatment are these fevers most likely to respond to. For this, I put them in broad categories. Are they, for example: 
- Feces fever (caused by microorganisms found in feces)
- Viral fever
- TB
- Tarai fever (caused by several parasites)
- Non-infectious fever, etc. 
Another big category I have invented is doxycycline fever. This pseudo-scientific category includes a whole bunch of fevers caused by atypical organisms that respond to an antibiotic called doxycycline.  

After talking to the patient and examining her, I tentatively put this patient as having doxycycline fever. But as you may guess by my wobbly expertise on fevers, I can never be confident. What if this patient deteriorates? There is every likelihood that I will never see this patient, even if this patient is visiting my hospital everyday, just because of the way disorganization works here. Patients bounce back and forth between departments without someone taking up a responsibility. If she goes home, which she is highly likely to do because of financial issues, who knows what happens in some remote corner of Kavrepalanchowk? So I asked them if they have cell phones. Both the father-in-law and my patient had cell phones. I took their numbers and explained to them that I want to try a medication which she can take at home. I told them they have to come to the emergency room if fevers do not go away in 1 week. Otherwise, I will call them in 2 weeks. I put a diagnosis of ?Brucellosis on my chart and prescribed her doxycycline. 

At 2 weeks, I called her. She sounded perked up, and rather overwhelmed that I called. She said she was doing very well. Fevers were gone, her appetite was up, she felt that she was back to her normal. 

It was a big relief. Based on the results, this might sound like a wise decision but it is hardly that clear at the time of decision making. We call this empiric treatment. A treatment decision made based on hunches without hard evidences. Especially in academic setup, like the one I work at, this is frowned upon. Primarily because we see patients everyday who are indiscriminately put on many medications without compelling reasons. We emphasize to our students and trainees that there should be evidences and compelling reasons to make treatment decisions. 

Yet, when you face social and financial constraints to do expensive investigations you will have to make decisions on empiric treatments based on your clinical judgement. It is a fine balance of how much to investigate and when to treat empirically. For short term illnesses like these febrile illnesses, I am getting much more inclined towards empiric treatments. It's hardly relevant to the patient if the fever was caused by Brucella or Leptospira or Mycoplasma. If the fever goes away and they can get along with their normal lives, structure of the cell membranes of these micro-organisms hardly disturbs their dreams.

As everything else in life, diseases do not always submit to clarity. This demands for an approach which is equally fuzzy. Perhaps this is when the realm of the art of medicine starts. 

Horrid Butchery

Samuel Gross, a trauma surgeon from the 19th century, had this opinion about thyroid surgery: Horrid Butchery. Thyroid is a very important gland in the lower part of the neck. Several maladies can ail this organ. Some of which, for example, cancer, require surgical treatment. But this gland is enmeshed with blood vessels; there are precarious nerves, large blood vessels, tiny but important glands, and airway in vicinity which make surgery quite tricky. From 19th century's Horrid Butchery, this operation has evolved to quite a safe surgery in trained hands. But risks are still substantial, especially if the operator is not well-versed and surgical safety protocols are not properly followed. Where I trained, we had national pioneers in endocrine surgery, and we endocrinologists felt safe to send our patients for surgery at a relatively low threshold if there was a reasonable indication for surgery. But I have had to leash my natural inclinations for my lack of sufficient knowledge about available expertise and facility for thyroid surgery in Nepal. I remind myself, this was once a Horrid Butchery, until I get a good confidence about our surgeons I will send patients to surgery only as a last resort. 

At clinic today, an intern came up to me to discuss a patient that she was seeing. The patient was sent to medical clinic from surgical department to get blood sugars controlled before surgery. This was a 69 year old woman from Saptari. She noticed some pain in the neck nearly 6 months back. When evaluated at Biratnagar, she also got an ultrasound of the neck which showed two small swellings in the thyroid gland. They biopsied these swellings. There was no evidence of cancer. She was given thyroid hormone with an idea that it may help shrink these swellings. But she continued to have some vague pain in the neck and was referred to Kathmandu for further evaluation. 

At Kathmandu, she underwent a repeat imaging of the thyroid gland which again showed those same swellings. One was described as complex (had areas of fluids separated by solid tissues) another was less than a centimeter in size. The radiologist, reported it as having a possibility of cancer based on the "complex lesion" and that it needed a biopsy for evaluation. She underwent a biopsy of these swellings: this did not have enough tissue to make a diagnosis. On the repeat biopsy, it was reported as not having any evidence of cancer. But the surgeon who saw the patient was worried about the report of possibility of cancer on imaging studies. So he decided to have patient undergo surgery. She was admitted to the hospital. But her blood sugars were out of control. Surgeons hesitate to operate when blood sugars are high because it increases the risk of wound complications. They consulted medical team. Medical team started her on insulin but blood sugars were still not controlled and surgery was cancelled. She was transferred to medical ward for blood sugar control and after a few days, since her sugars were still not controlled, discharged home with instructions to follow-up at OPD to adjust insulin dose gradually. 

Having been trained in the problems of thyroid, I looked at each of these investigations. The description of the "complex nodule" and also the printed pictures of the nodule was something called "spongiform nodule." For the size of the nodule that the patient had, it is recommended not even to biopsy spongiform nodules because the risk of this being cancer is very low (99.7% of these nodules are not cancers). So the radiologist had over-called the finding. The surgeon relied on a misleading interpretation. By this time, the patient had spent several days away from home in Kathmandu, many of those in hospital bed, scared she had a neck cancer, ready to have neck slit open, forget about the rupees than vanquished in this anguish. 

So what do I tell her? 

I explained to her what I thought of her problems and investigations so far and that her chances of having cancer is extremely low. I told her, if I were her or she was my mother, I would not have the surgery. She looked very relieved by this conversation. But she did ask, "Why did I have to go through all of  this?"

I do not know. I can not put blame on any one person. Radiologist over-called it, but it was not a mistake. They try to be safe than sorry. You do not want to miss a cancer but in this process you have some false positives. Surgeon was also not wrong to plan to take out the gland for a concerning radiology report. But what patient went through was a real hassle and a real risk. 

For me, this has been a lesson. A lesson in the backdrop of the debate on specialization. There is a rigorous debate about patient outcomes and specialty care. Studies are divided, some studies show patient outcomes are better with specialist care. Others show equally good or better, yet cost-effective care by generalists. So there are believers in specialist care and proponents of generalist care. Although I am a specialist, I have had warm feelings for generalist care. Especially in the context of resource poor Nepal. That is one of the reason I have been doing more of internal medicine at this public hospital, than my specialty of endocrinology. Besides, our public healthcare systems are so rudimentary and rooted in crisis mode (doing patch work for crises that come along) it just does not seem conducive for specialty care. 

However, with the event like above, it seems to me that specialist care will be profoundly important for Nepal. What this patient went through was a totally unnecessary hassle with an incredibly high risk. It could have been prevented if a trained endocrinologist had at one time evaluated the patient. It is not the same Nepal, from 8 years ago when we finished our medical schools. At 4000 rupees you can now get a CT scan and it seems like there are more Nepalis now who find paying few thousands of rupees not a very big deal. Multinational laboratory chains have made it possible to get any lab test you want done for few extra bucks. The volume of investigations patients go through is astounding. Perhaps done unnecessarily many a times, driven by profit motives, in many of these for-profit institutions and private practices where they get financial remuneration for ordering lab works. Accordingly, complexity of information available on the patient's illnesses and lab findings is growing massively. This gives an opening for misinterpretation of these lab and investigations results. There has to be someone who can focus on specific areas and build expertise to interpret these complex results.

Study data on specialists vs. generalists may be one thing, but when I think about this patient, and ask myself, instead of me if any other endocrinologist had seen this patient, would they have prevented this hassle and risk? The answer is a solid yes. These are basic stuff in our training. 

There must be several other patients who are getting their sugars controlled right now. They will undergo a Horrid Butchery with splendid sugar levels. Knowing that these patients did indeed need surgery would be nice. Wouldn't it?