The Consultation Room

Prof. Dr. CMK. Reddy

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

Chapter 101: Twelve Commandments

Twelve ‘Commandments’ for ‘healthy and litigation-free’ medical practice, compiled by me in 1990, are very crisp, easy to practice guidelines, to satisfy our patients and to maintain safe ‘social distance’ from the lawyers. They are self explanatory and most of them have already been covered in detail in various chapters :

i. Tidy appearance & warm reception

ii. Encourage free communication & clear all their doubts

iii. Explain therapeutic options & involve them in decision making, to the extent possible

iv. Outline the risks involved, obtain informed consent & never guarantee cure

v. Be punctual & available for emergencies (at least on phone)

vi. Maintain proper records & prompt correspondence

vii. Be considerate, non-commercial & avoid advertizing

viii. Join professional organization, read literature, attend CMEs, update yourself & practice evidence-based medicine (EBM)

ix. Respect co-practitioners & be willing to get a second opinion

x. Observe ethics, know the statutes & act judiciously

xi. Do some free service & involve in community service activities

xii. Don’t forget your family & children

Chapter 102: Telemedicine

‘Tele’ (Greek)=distance; ‘mederiâ€ (Latin)=to heal. Although initially considered futuristic and experimental, telemedicine is today a reality and has come to stay. It has a variety of applications in patient care, education, research, administration and public health.

Worldwide, people living in rural and remote areas struggle to get quality medicare and often have no access to specialty healthcare, primarily because specialist physicians are concentrated mostly in urban areas.

Telemedicine has the potential to bridge this distance and facilitate healthcare in these remote areas. The necessity of Webinar meetings, CMEs, video calls and online consultations by senior Doctors has increased recently, thanks to the pandemic. Robotic surgery is yet another, sofisticated application of telemedicine or rather telesurgery.

Since the 1950s, healthcare providers have been offering remote services. Telemedicine first began on landline telephones. With the advancement of technology, it has grown to offer services in a variety of ways. This includes online portals managed by your personal physician, video software, that allows for remote consultations and apps managed by companies offering telemedicine services.

Telehealth is broader term, to include distribution of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention and monitoring.

Infrastructure required:

i) You need sufficient bandwidth to transmit audio and video data (50-100Mbps or Megabites per second). In a rural set up, there may be difficulty connecting to or obtaining affordable and reliable broadband service.

ii) Imaging (video) technology or peripherals are the backbone of telehealth. They allow rural health organizations to see and hear patients even when they are miles apart. Digital stethoscopes, for instance, can transmit heart and lung sounds to remote providers.

iii) Technical support staff can help installation and answer questions about telehealth programs. To help financial efficiency, technical support staff may be shared across the collaborating organizations.

In view of the cost and the required technical manpower backup, at present, this facility is available mostly in corporate set up.

Doctor: Due to new privacy regulations we can no longer use patient names in the waiting room…

Chapter 103: Etiquette & ethics

Etiquette is defined as our attitude and behavior towards our professional colleagues, including paramedical persons. This subject is already discussed in detail earlier. Next to expertise, ethics is the most important virtue of a Doctor, which is appreciated by the profession and public and remembered long after we leave this world.

The list outlining the principles of medical ethics, virtually dictates the nobility and virtuous life style of a Doctor. Some of them might have been already discussed in detail in other chapters, but to recaptulate for comprehension:

Upholding the dignity decorum befitting the profession even in day-to-day public life, cordial, empathetic behavior with patients and colleagues, projecting a professional, noncommercial attitude.

Respecting privacy and modesty of patients, maintaining secrecy of matters revealed or discovered by you, including autopsy (exceptions : insurance company, court of law, health authorities, children and mentally challenged).

These are some activities by a Doctor, considered unethical :

to employ unqualified Doctors, nurses and other paramedics

to employ touts or agents to bring clients

to receive commission or kickbacks from diagnostic centres as ‘interpretation’ fees

to have commercial interest in pharmaceutical companies or pharmacies

to have ‘unhealthy’ relationship, including adultery, with patients or the family members

to give illegible prescriptions, with a probability of pharmacy giving a wrong medicine

to do offences involving moral turpitude, leading to conviction by a court of law

to issue false or misleading medical certificates to employer, court or insurance company

to withhold notifiable diseases or statistical data from health authorities

to perform abortion without proper medical indication or for purposes of female genocide

to refuse to provide emergency life saving treatment, without a valid reason

to supply scheduled drugs, without proper licence and protocol

to indulge in dichotomy (sharing fees with the referring Doctor)

to put up unusually large name boards, with any material, to attract clients

to refuse to provide medical services on racial, religious or community grounds

to discharge duties in an inebriated condition (alcohol or drugs)

to use Red Cross emblem, except by the Army Medical Services

(Geneva Convention – Article 7 of 1864 & Article 38 of 1949)

to practice secret or magic remedies, not in accordance with science or pharmacopeia

to conduct experiments potentially hazardous to patients, without their informed consent and the approval of the Ethical Committee of the Institution

to practice euthanasia (in countries where it’s not legal)

to perform organ transplantation with commercial interest

to treat medicolegal cases without proper documentation or informing the police

Basically a Doctor, member of a noble profession and a respected citizen, should be law-abiding, familiar with statutory requirements related to medical practice and act judiciously, not only while discharging his professional duties, but also in normal life.

Chapter 104: Japan’s secret for success

It’s exactly 76 years ago (in 1945), during the World War II, US bombed Hiroshima and Nagasaki (Japan), devastating the entire country. It’s amazing how the Japanese worked and resurrected their economy, to become leaders in various fields in the world market.

There’s a story: a Japanese and an American were walking in the forest and saw a tiger running towards them from a distance. The Japanese guy started tying his shoe lace, so that he could run fast.

The American asked him ‘are you foolish, can you outrun a tiger?’

The Japanese replied ‘I don’t have to outrun the tiger, if I can outrun you, I’m safe’.

This is how they conquered the world market. The moral is, you don’t have to be the world’s best, if you show an edge over the next man, you win the race. This applies to all walks of life, including medical practice.

Chapter 105: Concluding philosophy

What an agnostist calls as god, the scientist (or rationalist) calls it nature, which has tremendous healing (or mending) power and basic animal instinct of struggle for existence is always at play, to put the life back on the track.

We also have ‘karma’ theory that most of the happenings are predetermined and manifest under conducive circumstances. It says, like drugs, we all come with a prefixed ‘expiry date’ and there’s no escape from it.

It’s said in Bhagawadgita, ‘karmanye vaadhikaarasthe, maaphaleshu kadhaachanaa’, which means we only do the actions, but have no control on the outcome, the results are decided by the god (or nature). It’s also said, ‘Dharmo rakshathi rakshithah’, if you follow ‘dharma’ in all your actions, it shall come to your rescue, in times of need.

Dualism:

Researchers want us to understand modern medicine by separating body from mind â€“ while mind is superior to body, as it constitutes the uniqueness of the human soul (the province of theology), body is inferior to mind as itâ€™s a mere matter. Medicine simply considers the body as a machine.

While Dualism dominates clinical approaches to medical research and treatment, the legitimacy of the split between mind and body has been consistently challenged from a variety of perspectives, but experienced clinicians agree.

The therapeutic rationale of certain forms of treatment, such as hypnosis, faith healing, acupressure, music therapy, magnetotherapy etc. practiced by many, is yet to be fully understood, but certainly worth consideration.

It may be prudent for the young scientists to remember the three Murphy’s rules (Edward Murphy was an American Aeronautic Engineer, 1918-90) and the 4th one added by us :

i) More complicated a procedure, more chances for it to go wrong.

ii) During the entire procedure, if there is anything that ‘can’ go wrong, it ‘will’ go wrong.

iii) If you think everything is going on well, you might have overlooked something important.

To these, we added another caution:

iv) Don’t trust mother nature too much. Nature is generally good and supportive, but we don’t know about patient’s ‘nature’.

Medicine remains a venerable and noble profession even in an environment of a rapidly changing social, technological, corporate and governmental influences. Unlike in other walks of life, there is a constant demand on a Doctor’s time and one has to try and balance his professional, social and personal life.

It is the solemn duty of the present generation of Doctors to strive to uphold the quality and sanctity of medicine and pass it on to future generations. ‘Medicine may cure some, relieve often, but should comfort all’.

Finally one should realize that the patients appreciate the expediency, cost-effectivity and transparency of a Doctor, who is kind, honest and empathetic. Nurturing this kind of attitude towards our ‘clients’ is the core professional character, that makes it ‘noble’ and leaves no room for mistrust and litigations.

The Consultation Room