The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 26: Diagnosis & surveillance

It’s said ‘three important things in the management of any disease are, Diagnosis, Diagnosis & Diagnosis’. ‘If you make a rare diagnosis, you may be rarely correct’. But it’s also said ‘if we don’t diagnose rare conditions, they become still rarer’.

External conditions such as skin diseases, lipoma, dermoid or sebaceous cyst, Dupuytren’s contracture, parotid swelling, cleft lip, torticolis (wryneck), hemangioma, varicose veins, phimosis, hydrocele (in the scrotum or neck of a child), inguinal or ventral hernia, hemorrhoids, prolapsed rectum or uterus etc. known as spot diagnoses, can be identified by mere inspection.

Some minimum investigations are required for many diseases and more elaborate studies needed for a few. Most of the time, thediagnosis can be reasonably arrived by good clinical examination, radiology (imaging), biochemistry, microbiology, immunology, cytology or histopathology (tissue diagnosis). Immunohistochemistry (IHC) gives us further confirmation and sub classification of lesions.

‘The abdomen is a temple of surprises’, once a very popular adage, has become an ‘open book’, with the advent of noninvasive imaging and fibreoptic endoscopies. For deeper, inaccessible lesions, image-guided biopsy may be required to establish diagnosis.

Diagnosis and staging malignancies have become very easy with Positron Emission Tomography (PET) scan, which gives us both anatomical and functional details, also used to monitor response to therapy. Biochemical tumor markers are very useful for posttherapy surveillance, in conditions of thyroid, ovary, prostate, neuroendocrine tumors etc.

Giving full account of the applications of various diagnostic tests is beyond the scope of this book, suffice to say that with the availability of more and more advanced, sophisticated studies in various fields, the number of undiagnosed (enigmatic) conditions become less and less. It should also be cautioned at this juncture, we should be aware of the limitation of every test, in terms of its sensitivity and specificity, before we can draw inference.

A test is more sensitive, if it gives few false negatives and it’s considered more specific, if it gives few false positives. A negative needle biopsy has to be viewed with caution, due to possible errors of sampling and interpretation.

 

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Chapter 27: Scheduling a procedure

Minor procedures, such a drainage of a superficial (subcutaneous) abscess, suturing a minor laceration, punch biopsy of an ulcer tongue, cheek, cervix uteri, rectum or skin, core (tru-cut) needle biopsy of a not-so-deep, >3cm sized mass, placement of secondary sutures, paracentesis of abdomen or chest, suture/clip removal etc. can be safely done in an office set up.

Major procedures requiring admission and anesthesia, have to be scheduled in hospitals, where the Doctor has privileges. However the choice of the hospital depends on the infrastructure required for the particular procedure, availability of room and operation theatre, tariff structure, presence of insurance cover and of course, the patient’s preference, if any.

The patient has to be adequately counseled, all his doubts cleared including approximate total cost, number of days required to be in the hospital and any relevant preoperative instructions. Under instructions of the Doctor, this process is usually carried out by an experienced receptionist, including collection of some advance amount from the patient for the service of the Doctor.

It’s also important that the co-morbidities of the patient, such as anemia, diabetes, hypertension, ischemic heart disease, COPD, hypothyroidism, convulsive disorder, azotemia etc. are properly addressed.

 

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“Your health Insurance doesn’t covers heartburn. You need fire insurance for that.”

 

Chapter 28: Informed consent & refusal

This is usually required for patients to be admitted for surgery and not for out-patient care. Since it’s a legal document, all the prescribed formalities have to be followed, properly recorded and signed by the patient/guardian and some relative/attendant as witness.

All those who signed, have to be properly identified in capital letters and the document kept in safe custody. However, if the patient refuses admission or a particular investigation as advised, it is also recorded in his file and signature for ‘informed refusal’ obtained, to avoid future litigation.

Since there are no hard and fast rules, we always have a dilemma, how much to inform the patient, regarding his illness, the proposed operation and the complications. As a general rule, only probable (and not possible) complications need to be discussed, before getting the consent. If we narrate all ‘possible’ complications of an operation to the patient, many may hesitate or refuse to give permission.

The wisdom and judgment of the Doctor, dictated by his experience, should guide him how much to ‘disclose’ to the patient. In any event no guarantee should be given about the outcome of any major illness or procedure, since ultimate result depends on so many factors, beyond the control of the Doctor.

If the patient is a minor, parent or guardian should sign the consent form. In an emergency situation, such as an accident, requiring immediate intervention, if no one who has the legal authority to sign, is available, a second opinion from a senior Doctor may be recorded, before proceeding with the ‘life-saving’ procedure. The family members, however, should be contacted and the critical situation explained on phone and oral permission obtained, which may also be recorded.

Chapter 29: High risk consent

This is obtained when the outcome of a procedure is uncertain, but it has to be done to save life. It may be due to age, comorbidities or the nature of the procedure. It is preferably handwritten in patient’s own language, outlining the reason for the additional risk and the need for the procedure.

Besides the patient, at least two of his close relatives should sign and identify in capital letters. Not only it provides additional legal safety, it also prepares their mind to accept some adverse outcome, if such a contingency arises.

Before leaving this subject, it’s important to realize that obtaining a ‘proper’ consent for a procedure does not provide immunity against litigations, arising out of professional negligence, incompetence or deficiency of service and so on. However, if a procedure is done without a proper consent, it may become a criminal affence, hard to defend.

 

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Chapter 30: Overlapping specialities & systems

In Indian scenario, this is unavoidable to overlap into areas other than ones specialization. Most of the specialists do some family practice as the situation warrants and some maintain two clinics, in one as a GP and in the other as a consultant. Many general surgeons are ‘all rounders’ depending upon their training background and force of circumstances.

Hysterectomy and Cesarean section are the classical such examples, which are commonly performed by general surgeons, family physicians and of course by gynecologists. In moffusil practice, spinal anesthesia is usually given by the surgeon himself, monitored during the procedure by one of his assistants, due to nonavailability of anesthesiologists.

We know one General Physician (MD-Gen), while working in Railway service as Medical Superintendent, started doing closed mitral valvotomies (CMV), that he was honored by awarding ‘Padma Sri’ by the Govt India for doing large number of those operations successfully.

According to the Medical Council rules, there is no bar for even MBBS (Bachelor of Medicine & Bachelor of Surgery) Doctor to perform any ‘not-so-complicated’ operation, provided he has had the necessary training and expertise and the hospital has the required infrastructure, to justify in the event of developing some complication.

It is also common knowledge that a General Physician (Internist) overlaps into various specialty areas, out of sheer necessity, in his practice. Similarly many ENT surgeons do head & neck surgery, including thyroid and it’s still an unsettled issue, who is the preferred specialist to do disc surgery, neuro or ortho surgeon. Excision of cervical rib ‘enjoys’ maximum overlap of specialties: neuro, ortho, vascular, thoracic or a confident general surgeon (trained in vascular surgery).

These lines of specialization are strictly drawn in major tertiary care centres, but not so in primary and secondary care hospitals. Many teachers in non-clinical departments such as anatomy, physiology, biochemistry, pathology, forensic medicine etc. do family practice, during their spare hours.

I know one postgraduate (MD) in Social & Preventive Medicine (SPM), had a very busy practice as ‘General Physician & Cardiologist’ in Chennai, by just omitting to put SPM in brackets after MD, on his name board and prescription pad.

The Supreme Court had clearly stated that a Doctor qualified in any system of medicine, is prohibited to practice other systems. However there are many ayurvedic or herbal products (used in liver disease, urolithiasis, prostatic disease etc) ‘adopted’ by allopathic Doctors and are available in regular pharmacies.

Further, in an attempt to encourage Doctors of alternate systems of medicine, the Govt of India has decided to give them more privileges. When the physiotherapists started putting ‘Dr’ before their names in the past, the medical fraternity vehemently opposed and successfully prevented it.

We have to wait and see the developments regarding the recent decision by the Govt to allow Ayurvedic Postgraduates to perform ‘minor’ general, ENT, ophthalmology, dental and orthopedic surgeries (total 58 operations listed), how the Govt is going to push the idea forwards and how the medical (allopathic) community is going to react.

The way Govt looks at it is, when the qualified allopathic Doctors are not keen on settling in rural areas, allowing mushroom growth of quacks, this may be a better option, besides promoting Indian medicine. However the logistics of anesthesia, pre and postop care, use of antibiotics, intensive care, treatment of postsurgical complications for such procedures done by Ayurvedic ‘specialists’ haven’t been clearly defined, throwing the debate of the issue wide open.

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