The Consultation Room

Prof. Dr. CMK. Reddy

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

Chapter 36: Well informed patient

With increasing level of literacy and the plethora of information in various media, it’s no surprise, many patients do lot of ‘home work’, before coming to us and we have to carefully watch our words, while interacting with them.

We should also be prepared to face some insinuating or uncomfortable questions such as, ‘how many such operations you’d done before and what were the results, immediate and long term’? Is the Hospital you’re suggesting, sufficiently equipped to handle postoperative care ? Are you planning for conventional bypass (CABG) or beating heart surgery ?’

One patient came to me from a remote place in another state for lap cholecystectomy. I knew that there’re many good surgeons in his town, so I asked him why he all the way came to us. He said ‘yes sir, I know there are many surgeons, but they’re all laparoscopic surgeons and not competent ‘open’ surgeons. I wanted some one who’s also a good ‘open’ surgeon, if conversion is required, for some reason during the procedure’.

“Here is the mood elevating medication that your Doctor prescribed. The less costly generic version is called chocolate.”

Chapter 37: Technical explanation

It’s better have some pictorial anatomical charts of various parts of the body in the office, so that the patient may be properly explained about the disease, it’s probable complications and proposed treatment.

Otherwise, the Doctor should draw a sketch diagram of the concerned part and explain the matter. Readymade pictures of the area of Doctor’s specialty, would be very handy in such situation and the patient may carry it to show to his people, if he wishes.

The level of their capacity to understand has to be assessed, before we decide the depth of meaningful technical discussion with them. Sometimes, it may be better that they don’t understand at all, than to misunderstand.

It may be difficult for the Doctor to explain certain exercises required to patients for some conditions, such as cervical spondylosis, thoracic outlet syndrome, low backache with sciatica, postpartum excercises of abdominal muscles, postmastectomy shoulder exercises etc. Best method is to record them as videos in your mobile phone and show or forward to them, to follow.

Chapter 38: Prescription

Obviously this is the fruit of our medical science, ultimately the patient is going to eat. As already indicated, it’s much better a tentative prescription is formulated soon after the first visit, when the memory is green, about all the details. Suitable alterations may be made, after reviewing the lab reports.

Giving an appropriate and comprehensive prescription, covering all aspects of the patient’s ailment, is an art, choosing from plethora of options available. Many Doctors, who may be academically sound, but fail in the application of their mind, while formulating the prescription.

It has been our experience that out of ten patients we see in office, 1 or 2 may require surgery, unless the Doctor strictly sees only patients referred by Internists. It has also been observed that more experienced you become in profession, less number of medicines are prescribed and indications for surgery also become more strict.

Barber (1995) recommended that we should consider four important aspects, while prescribing a medicine:

minimize cost,
minimize harm,
derive maximum therapeutic benefit and
respect patient’s choice.

Let’s remember that ‘remedy should not be worse than the disease’. The prescription should be legible, best written in capital letters or printed, to avoid pharmacist giving wrong medicine, for which the Doctor also shares the legal responsibility for the damage that might occur. If any of the drugs prescribed has a sedative property, the patient should be so cautioned and advised to avoid driving a vehicle, for a specified period, after taking that medicine or still better, to take it at bed time. You all know the story about a Doctor while on tour, wrote a letter to his wife and she had to take it to their pharmacist to read it. Of course, with the advent of social media, nobody writes letters any more.

The patient should also be cautioned about change in urine color that may occur with some common drugs :

Orange:

isoniazide, sulfasalazine, nitrofurantoin, metronidazole, paracetamol

Red:

rifampicin, warfarin, phenazopyridine (Pirydium), ibuprofen

Blue or green:

amitriptyline, indomethacin, cimetidine, metoclopramide

Yellow:

mepacrine (antimalarial), riboflavin

Motion may turn black with preparations containing iron.

‘Every patient has to recover twice, once from illness and again from the medicines’

“Cause of death was an unexpected post-surgical complication.

His wife caught im flirting with a nurse.”

Chapter 39: Medical Council guidelines for a prescription

With the recent notification of the Govt of India and the MCI, indeed many medical practitioners have been left confused on how to go about writing their prescriptions. Yet Doctors also need to keep in mind that there are many essential, sometimes legal requirements, that are mandated in writing a prescription, a routine, but most significant task. Here are the very elaborate guidelines:

Minimum sizes of the Prescription pad:

Depending on the requirement, two sizes of pads are suggested, they are either 21×14 cm (A5 size) or 11×11 cm.

Details of the Doctor:

Doctor’s full name, details such as qualifications, address, consultation timings, telephone numbers, Medical Council Registration number (& Registering authority), should be printed on the letterhead.

Only those degress or diplomas received through convocations should be mentioned. At the bottom, Doctor’s signature and date in indelible ink, are required to verify the authenticity of the prescription, in order to prevent misuse. Use of ‘Rx’ superscription, not a legal requirement, but most often used as a matter of practice, which comes from the Latin ‘Take Thou’.

Details of the Patient :

Patient’s full name, gender, age, weight, address and telephone number, to be shown at the top.

Details of the Medicines:

Name of the medicine – write the Generic Name in CAPITAL, with the brand name/Company or any other name in brackets. Strictly avoid abbreviations or scribbling the name of the medicines.

Strength or potency of the medicine, form and dosage – eg: capsule, tablet or syrup etc. dosage & dosing instructions, total quantity & Refill information. If the Doctor wants the prescription to be refilled, he should clearly write the number of times it may be refilled. This is very important to deter patients from repurchasing medicines (on their own), from the same prescription, again & again, which may be potentially harmful. A rubber stamp, containing Doctor’s full name and Reg no. should be affixed below his signature, also to prevent abuse.

It’s a pity that the process is made so cumbersome, for which our Doctors are not primed, though it may be necessary, it hasn’t yet become a routine exercise by many, thanks to the inefficient monitoring system. Unfortunately, the law makers overlooked the plight of a general practitioner, especially in rural or suburban areas, who sees (has to see, rather) more than 100 patients in a day, with poor education and paying potential.

“I already diagnosed myself in the Internet.

I’m only here for a second opinion.”

Chapter 40: Remembering names of drugs

It’s always difficult to remember the names (both generic and trade) of newer drugs entering the market. When you are impressed about a newer molecule or drug, found in the literature or when the medical representative details about it, it’s better to note it down in a booklet, including the name of the manufacturer, indication, prescribing information and the price.

Of course this booklet is only for your private reference, may need to be periodically updated, removing those, you have already become familiar, from the list, so that it would be succinct and easy to refer, when you are sitting with a patient. To make it still easier to refer, we can put them in a classified manner, systemwise, by the indications. This will certainly improve your prescribing efficiency, utilizing some very useful latest drugs available in the market.

You may also refer to any Drug Info Book, such as Current Index of Medical Specialities (CIMS) or Physician’s Desk Reference (PDR), for prescribing guidance. If there’s internet facility in the consultation room, you can browse ‘medplusmart.com’ and go to ‘pharmacy’, ask for medicines prescribed for a particular disease and select from them, to get the generic formula, brand names, dosage, price and the manufacturers.

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