Complications are bound to happen, what is important is how you tackle them

Medicine is an art, based on science, yet it is not an exact science. And it is the skills that the doctor picks up first during his education and then as part of his training, which help him to safely and effectively practice medicine. Years of clinical practice then further his knowledge and add to the skills.

No two patients are alike; every patient is different and clinical decisions are tailored to individual patients. Therefore, probability and uncertainty are part of the practice of medicine where complications are bound to occur. But what is of the utmost importance here is to anticipate potential complications and manage them quickly. When any complication is anticipated, one is prepared accordingly to handle it.

It is this ability to anticipate, recognize and the quickness shown in managing any complication that marks a distinguishing characteristic of a “good” doctor and sets him/her apart from others.

To acquire these clinical and procedural skills, a doctor undergoes years of rigorous study and training. Only then, do they acquire adequate knowledge, discernment and develop skills to take the right decision for the patient and adapt to changing practices. But, today quacks are flourishing in our society. They are obviously untrained and lack the ability to diagnose or treat patients, in particular any emergency or complication. They cannot render timely first aid. Although it is their routine practice to refer patients to hospitals or higher centers, but precious time is lost. They can hardly be expected to be aware of the concepts of the “Golden hour” or the “Platinum 10 minutes”. And, the outcome often is patient succumbing to his illness.

Quacks also prescribe antibiotics, which are Schedule H1 drugs. Misuse of antibiotics by quacks fails the very objective of Schedule H1, which is to control the rampant use of antibiotics and anti-TB drugs to check the epidemic of antibiotic resistance.

Schedule H1 drugs, along with Schedule H and Schedule X drugs, are restricted drugs and cannot be sold to just anybody OTC. A valid prescription from a doctor of modern system of medicine is required before they can be dispensed to the patients.

The Govt. is promoting AYUSH doctors to practice modern medicine. Scheduled drugs should only be allowed to be written by MBBS or BDS doctors. The prescription of Schedule H, H1 and X drugs by non-MBBS, non-BDS doctors can cause large-scale harm.

Interpretation of a situation or judgment in the body is governed by chemical reactions and is controlled by the balance of autonomic balance system, which in turn is governed by the interaction of parasympathetic and sympathetic nervous systems. 

Sympathetic mode releases stress hormones and may trigger panic or nervousness, the “flight or fight” response. This prevents a person from taking the correct and decisive decision and increases the chances of mistakes, which in the case of a doctor may be costly. It may mean life or death for this patient.

A parasympathetic state of mind, on the other hand, is quiet and composed enabling rational and Right conscious–based decisions and just the right frame of mind to tackle complications. Doctors should practice medicine in a parasympathetic mode. 

Dr KK Aggarwal

National President IMA & HCFI

Beware of monsoon illnesses, says IMA

Precautionary measures and eating the right food is ideal to avoid the onset of diseases

New Delhi, 05 July 2017: The hot summers are gradually giving way to the monsoons, and along with them many diseases and reduced immunity as well. There are many diseases associated with the monsoons such as malaria, dengue, Chikungunya, jaundice, and gastrointestinal infections like typhoid and cholera. Apart from these, viral infections like cold and cough are also common.

The water that gets collected due to rain becomes a breeding ground for mosquitoes. Another common observation during this period is the contamination of drinking water which gives way to diarrhea and gastrointestinal infections. Walking in dirty water during the rainy season also leads to numerous fungal infections, which affect the toes and nails.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said "The rains not only bring with them the much-needed respite from heat but also a number of diseases. Patients with chikungunya typically have extreme joint pain. Dengue, if not adequately managed, can be fatal in 1% to 4% of the cases. Chikungunya can cause chronic debilitating joint pains that can sometimes last for years. Management of dengue involves fluid resuscitation and not platelet resuscitation. If enough fluids are given, mortality can be reduced. The mortality period usually starts when the fever subsides. Misusing anti-fever medicines can precipitate bleeding in dengue patients."

Diabetic patients should ensure that they take care of their feet and be aware of infections affecting the toes and nails. Feet should always be dry and clean and it is better to avoid walking in dirty water. Those with asthma should take precautions to prevent dampness and growth of fungus (mold) in and around the house.

Adding further, Dr Aggarwal, said, "During the rainy season, underground worms come to the surface and contaminate vegetables. In the presence of a weak digestive fire, this can cause gastric disturbances. Therefore, it is also better to avoid any community lunches and marriages in this season. Eat light foods and consume barley, rice, and wheat. Water should be boiled before use and consume warm food. Adding ginger and greens to your daily diet is a good idea."

Additionally, skin care is also an important factor to consider in this season. The skin needs extra pampering because temperatures drop and the wind and rain can put strain on the skin. Dandruff is very common in the monsoon due to humidity and overgrowing of malassezia furfur fungus. Breakouts, acne, and bacterial infections also get aggravated by wet clothes. Fungal infections like ringworms are common in areas like the armpits, groin, and between the toes.

Here are some other things to follow during this season.

• Consume hygienic food
• Keep the hands and feet clean
• Do not allow water to stagnate
• Dry your hair after bath
• Increase consumption of Vitamin C 

Autism, a highly misdiagnosed condition in India

Patience and love along with therapy can a child and families and children cope with this condition

New Delhi, 04 July 2017: According to a recently conducted study, 1 in 89 Indian children between 2 and 9 years of age are diagnosed with autism. As many as 2.2 million children and 13 million people in the country live with this condition. It is alarming to note that while the cases of autism are showing an upward trend in India, there is not much awareness about this condition. There is also much stigma associated with autism in India.

The signs and symptoms of autism can be observed in the first three years of a child itself. This condition is the outcome of a neurological disorder which affects normal brain function, communication, and social interaction skills in children. Although the exact cause of this disorder is not known, research points to a combination of genetic and environmental factors.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, "Autism is a highly misdiagnosed condition in India. Many still treat children with autism as abnormal and mentally deranged and therefore, diagnosis gets delayed further. The earlier it is diagnosed, the better it is for the child. In children with this disorder, certain information processed by the brain is sent out in the form of signals that are just noise for him/her. Autistic children find it difficult to distinguish vital signals from this noise. The brain develops differently in autistic children and some are brilliant in few things although they may be unable to communicate as effectively as others. While an autistic child may be unable to speak clearly, he may turn out to be excellent in something else."

The Indian government now recognizes autism as a disability. Although autism was thought to be incurable till late, there have been improvements and therapies such as art therapy have been found to help this condition somewhat.

Adding further, Dr Aggarwal, said, "There is no single line of treatment for children with autism. A treatment approach that encompasses addressing social, language, and behavioral difficulties is the key. Parental and family support is highly important in treating such children. It is a good idea for parents and other members of the family to learn how to interact with them in ways that promote social interaction skills, manage problem behaviors, and teach daily living skills and communication. Certain medications are also prescribed for hyperactive children."

Life is not very easy with an autistic child. There may be new challenges every day. However, it is important to acknowledge the condition and accept it. Celebrating every accomplishment of your child however small it may be, have a lot of patience, love them unconditionally, and putt in consistent effort. Here are some tips for parents of children with autism.

• Be aware and focus on the positive Autistic children, just like others, respond to positive reinforcement. Praise them for any small milestone they achieve and for any other good behavior they exhibit.
• Give it time Nothing works overnight and this is true of therapy and treatment as well. Do not get discouraged if your child does not respond to a certain line of therapy.
• Get support Try and look around for similar groups of parents as this will help you share advice and get support on various aspects.

Outstanding and Receivables: A Long overdue problem faced by service providers

Doctors are not a happy fraternity today. There are several reasons for this.

• Practicing doctors live in fear of criminal prosecution or violence.
• Specialists are unhappy because of the unrealistic targets they are expected to meet.
• Corporate hospitals are unhappy because they are denied their due reimbursements in time.
• Service doctors and medical faculty are unhappy because their salaries are not at par and the new 7th Pay Commission has reduced the non- Practicing Allowance (NPA).
• MBBS doctors are unhappy because they do not have opportunities to get a postgraduate degree.

The medical profession provides services to Central Government Health Scheme (CGHS), Employees Health Scheme (EHS), Public Sector Units (PSUs), Ex-servicemen Contributory Health Scheme (ECHS) and similar organizations at highly subsidized rates. Yet the due reimbursement is delayed for months together and is given without any interest.

This was among the several issues that I had touched upon in my Presidential address. Therein I had said, “The constitutional right “equal pay for equal work” should be implemented in medical profession. All service doctors and resident doctors should get full 7th Pay Commission, obligatory research grants, uniform age of retirement and uniform nationwide pay scales, legitimate leaves, and working hours and conditions.”

Then again, “Uniform service conditions for doctors and faculty” and “Reimbursement of emergency services for private sector” were a part our major demands in the Dilli Chalo movement.

Let’s review here the problems faced by service providers.

• Service providers empanelled with the above organizations are in a very vulnerable position. Providers cannot deny services to these patients as the number of beneficiaries is large and ceasing services will cause a public disaster.
• With services being continued, the government has gone into a state of inertia and apathy.
• The service providers are struggling with operations and continuation of service due to the following main challenges:

o    Delayed reimbursements: The current situation of outstanding is alarming with payments worth hundreds of crores pending. For example, the outstanding amount from CGHS includes up to 75 crores of Max Healthcare, over 20 crores of empanelled hospitals of Fortis in the north, in Bangalore and Maharashtra and about 5 crores of Dr Lal’s Path Labs.

This excessive delay is affecting the very sustainability of the operations for the service providers. As a cascading effect, lab providers face delay in other payments from hospitals as they do not have enough funds to pay the labs because of delay in receiving reimbursements. While the service agreement provides for 70% of payment within 5 days, payments are delayed by months. An intervention from the Finance Ministry is also required to rectify the current problem as delays are also caused due to misalignment between Ministry of Finance, Ministry of Health & Family Welfare and the payment partner- UTI

o    Wrongful Deductions: - Even though service providers are deliver services as per rates given by the Government, illogical deductions are made from the claims with no intimation to the service providers. The quality of service and costs involved are judged by inadequately qualified persons during claim processing.

o    Reconciliation Issues: Several gaps exist in the current system of dispute resolution and arbitration for such cases. There is a need of validation of the system by an independent body, maybe FICCI Indian Council of Arbitration (ICA). Grievance redressal for service providers should be relooked into and streamlined

o    Contract Renewal and Extensions: The agreement, which is valid for 2 years, has been extended up to 4 years by the Government, without citing any rationale for the extension. The current contract due to expire in October 2016 was extended up to end of June 2017 and still there is no sign of new agreement.

o    Terms of Agreement: Agreements should be restructured before upcoming renewals to account for the following:

- Organizations like CGHS should have a mechanism to accommodate inflation like in case of the Pharma Industry where price hike of up to 10% every year is allowed.

- The Andhra Pradesh state Government order has been linked to Consumer Price Index (CPI), these organizations should also have similar considerations.

- The rates of organizations like CGHS should be based on a scientific rationale.

- Experts from the private healthcare sector should also be a part of the rate fixing exercise.

- A unilateral scheme with all specifications in favor of the government is not acceptable to the industry

(Source: FICCI Health meeting held on 13^th June chaired by Dr Girdhar Gyani)

IMA Resolutions on Doctor’s Day

Doctor’s Day, as we all know, is the day dedicated to the memory of Dr BC Roy. The day marks his birthday and it is also the day when his physical body left us. But his soul is still alive in our minds. This day also reminds us of our purpose with which we chose medicine as our profession and our responsibilities towards the community.

Hence, in a befitting tribute to this legend of medicine, on Doctor’s Day this year, the Indian Medical Association (IMA) took some resolutions.

• Our theme for “Doctor’s Day” for the year 2017 will be “My Family Doctor”.

• IMA will have “Zero Tolerance” for unethical practices by medical professionals and or medical establishments.  These include Referral Fee, Cuts, Commissions received without involving any services. Offenders can get their names removed from the primary membership of IMA.

• IMA will not tolerate any targets given to medical specialists who join hospitals.  IMA will soon come out with a standard appointment contract between consultant and corporate hospitals.

• IMA supports a “uniform code of medical ethics” for medical establishments, industry and doctors.

• IMA does not support criminal prosecution of doctors in clinical practice.  

• Medical or surgical consent should include not only the competency of the doctor or establishment to handle a procedure, but also competency of facilities available to handle complications. 

• IMA Awards announced on “Doctor’s Day” will be presented during Centenary Celebrations of Medical Conferences in India on 23rd & 24th September, 2017 at New Delhi.

• IMA will intensify its public image through “IMA Thank You” & “Public Health Awareness Campaigns” using various advertisement modules.

• IMA Accreditation and Academic Council will be operational from 15^th July 2017.  Dr KK Kalra Ex CEO NABH has joined IMA as CEO of the Council.

• IMA opposes reduction of Non Practicing Allowance (NPA) and delinking it to basic pay in the 7th Pay Commission.

Dr KK Aggarwal

National President IMA & HCFI

IMA announces awards and action points on the occasion of Doctor's Day

Importance should be accorded to family physicians and the nobility of the profession should be restored

New Delhi, 03 July 2017: With this year's theme as 'My Family Doctor', the IMA celebrated Doctor's Day on 1 July 2017. Among other activities held on this day, the IMA announced awards under various categories, which would be presented during Centenary Celebrations of Medical Conferences in India on 23rd and 24th September 2017 at New Delhi.

The Association announced Zero Tolerance to unethical practices by medical professionals and or medical establishments. These include Referral Fee, Cuts, and Commission received without involving any services.  Offenders can get their names removed from the primary membership of IMA. There will be no tolerance for targets given to medical specialists joining hospitals. The IMA will soon come out with a standard appointment contract between consultant and corporate hospitals.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "This doctor's day is about celebrating and honoring the tradition of the family physician. Family physicians looked after all the health needs of a family, even many generations of a family, regardless of their specialization. They treated and provided preventive health care to a family as a whole because they were aware of the family history and served as a link between the patient and the specialist. The society should be educated on the benefits of getting treatment through a family doctor. Apart from this, IMA has also announced many other measures as part of this day."

There should be a uniform code of medical ethics for medical establishments and doctors. The Association re-defines medical or surgical consent and that should include not only doctors or establishment’s competency to handle procedures but also the competency to handle complications how so ever rare they are.

Adding further, Dr Aggarwal, said, "The IMA does not support criminal prosecution of doctors in clinical practice. It should be understood that doctors are not healing angels. The situation today is that doctors now are being prosecuted in various special acts for non-professional activities like not wearing apron, not displaying a defined board or not keeping a copy of PC PNDT Act.  Doctors are also being prosecuted for minor violations of privacy, confidentiality of patient information and data and violations of minor clauses in surrogacy, IVF and HIV_AIDS acts. This is not acceptable to the medical profession."

The Association opposes reduction of NPA in the 7thPay Commission. IMA will also intensify its public image through 'IMA Thank You' and 'Public Health Awareness Campaigns' using various advertisement modules. Apart from this, the IMA Accreditation and Academic Council will be operational from 15th July 2017.  Dr K KKalra, ex CEO NABH, has joined IMA as CEO of the Council.

The recipients of the IMA awards are as follows: Women Empowerment Award - Dr Jayshree B. Mehta and Dr Soumya Swaminathan (2016), Dr Rishma Pai (2017): Doctor of the Decade Award - Dr A Marthanda Pillai and Dr Shashank Joshi (2016), Dr Randeep Guleria (2017); Life Time Achievement Award - Dr Vinay Aggarwal (2016), Dr Ved Prakash Mishra (2017); Doctor of the Year Award - Dr R N Tandon, Dr Girish Tyagi, Dr R V Asokan, Dr Hrishikesh D Pai, and Dr K K Kalra (2016), Dr Shiv Kumar Mishra, Dr Bhupender Ahuja, Dr Saumitra Rawat, Dr H P Saraf, and Dr Mona Desai (2017), Dr Bharti Kashyap; Medical Eminent Teacher Award - Dr Georgi Abraham, Dr C G Bahuleyan, Dr M C Mishra, and Dr J A Jayalal (2016); and IMA Eminent Nurse Award - Ms Anita Deodhar  and Ms Evelyn P Kannan

Consent Revisited: Inability to manage complications leads to violence

Consent, as we know, is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A doctor has to take consent from the patient before proceeding with his treatment. It is ethical and in today’s scenario, a legal requirement. Any act done without permission is “battery” or physical assault and is liable for punishment.

A valid consent has three components: Disclosure, Capacity and Voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion. This is informed consent. Any permission given under any unfair or undue pressure makes the consent invalid.

The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.”

No doctor practices medicine without taking informed consent. Yet we read and hear of incidents of violence against doctors from all parts of the country. So, are we going wrong somewhere? Are we doing something wrong somewhere?

“Medicine is an art based on science”, said Dr. William Osler. Complications, adverse events or untoward incidents may occur at any time during the treatment. What is important here, how competent, we are, as doctors, or how competent is the hospital or the clinical establishment, in managing these complications or untoward incidents in a non-emergent situation.

Not being able to manage complications leads to violence.

The patient should be informed of every possible complication that may occur during this treatment, however rare they might be; even a complication rate as low as 0.1% might be 100% for that particular patient. No surgery can be called as a ‘minor’ surgery.

Mistakes are made, but we believe that nothing will happen either to us or the patient. As I wrote few days back, it’s the case of "Kya pharak padta hai" to "bahut pharak padta hai". If nothing goes wrong, then "chalta hai". But, if something does go wrong or an unanticipated event occurs, then this becomes unacceptable “chalta nahi hai”.

The key word here is ‘anticipation’.

Anticipate what all can happen in the course of a treatment and be prepared to handle them or keep your patient informed. For example, you may need to shift the patient in an emergency to a higher care center and your establishment does not have an ambulance. Outsourcing an ambulance will delay patient transportation, and in an emergency situation, the longer the delay, more agitated are the patients or family members and may become violent.

Let’s take another example. You might need the services of a specialist, say a urologist, neurosurgeon, or a nephrologist. If your hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence.

Should you have these services and other such facilities as standby? Yes, everything must be on standby. The standby fee is 25%, while presence fee is 100%.

This may increase the cost of treatment. The time has come when the patient must know that safety comes at a price in bigger hospitals.

Inform the patient and the family members beforehand, let the patient choose and accordingly the consent should be taken. Safety of the patient is very important and should be our primary objective.

A small set-up may not have all facilities as their bigger and better equipped counterparts. These smaller set-ups should keep the patient and/or family members informed about this lack of facilities and take consent.

Good communication can reduce the rapidly increasing problem of violent attacks on doctors and healthcare establishments.

‘Adequate information’ for consent should include not only the competency of the doctor to treat the case, but also include the competency of the doctor and/or the hospital to manage any emergencies or untoward incident in a non-emergent situation. Any breach in this duty is negligence.

This, I believe, is an area which we need to work on. It is the inability to manage complications that leads to violence.

As doctors we SERVE our patients and the community and provide

·  Service which we have professionally trained for, which is

·  Excellent i.e. anticipated

·  Responsible, give our 100% to the patients and take responsibility

·  Value – Group; each member of the group knows the duties of another, so no gap in service may result

·  Enthusiasm: A positive happy atmosphere

This is how we can avoid incidents of assault and violent attacks on doctors from happening.

Dr KK Aggarwal

National President IMA & HCFI