The Consultation Room

Prof. Dr. CMK. Reddy

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

Chapter 96: Clinical trials

Generally it’s difficult and unethical to carry out double-blind clinical trials on patients coming to us for treatment, in an outpatient setup. Administering a controversial drug in one arm and a placebo in the other arm, may be potentially harmful to both and any such study on humans, without the clearance by the Ethical Committee of an institution is not legal.

Similarly doing an controversial operation, not considered standard, on a patient even with his ‘informed’ consent, but without the approval of the Ethical Committee, may invite trouble, if he suffers any damage out of it. Besides the liability of the compensation, it may attract criminal proceedings.

If you’re a participant in a multicentric study and the main author had already obtained the clearance from a properly constituted Ethical Committee, you are justified in carrying it, as a member of the team. It is advisable to consult the guidelines prescribed by the Indian Council for Medical Research (ICMR), available in their website, for further information, before we embark on clinical trials on humans.

A retrospective statistical study can be done from your database, without any permission or risk to patients, useful for epidemiological inputs, about a particular disease or a particular modality of treatment.

Chapter 97: Preventive healthcare

‘An ounce of prevention is better than tons of treament’. This is more relevant in the present scenario, with high cost of ‘quality’ medicare, beyond the reach of a common man. Neither the subject of Social & Preventive Medicine (SPM) is taught seriously in medical colleges nor an average practitioner has the time to focus his attention to preventive heathcare, in his day-to-day work.

Any Doctor who depends only on treatment by medicine or surgery, is considered incomplete. In the present global scenario, with shifting emphasis on natural remedies, we should also modify our strategies to suit the changing public moods and propagate alternate remedies through meditation, yogaasanas, pranayama, aerobic exercises, naturopathy etc.

We should impress upon our clients to always trust four important ‘Doctors’ for their positive health; Dr Diet, Dr Exercise, Dr Lifestyle and Dr Take-it-easy. ‘Meditation is better than medication’. It’s important to maintain optimal weight, carrying regular exercises (at least for 30-45 min, four times a week), avoiding unhealthy (fast) foods containing more fats, salt, rice and sugar, promote vegetarianism, oldtime habits like early to rise and early to bed, get good sleep and free bowel movement etc.

We should discourage people craving for ‘fast’ foods; they are probably so named because they lead us to heaven fast ! Proper and timely vaccinations are also important in all ages for various preventable diseases. The diabetologists tell us the ABCDE of glycemic control, to prevent complications, they are A1c (<7), BP (<130), Cholesterol (<200) & LDH (<100) and Dietary & other habits (tobacco, alcohol, weight) and Exercise.

Looking at the prescription given by a Doctor, one woman remarked ‘hope there are no side effects for these medicines’. The Doctor asked her ‘have you ever asked this question, while eating a pizza, burger or hotdog?’ We talk about of pollution of air, water and noise, but how many think about thought pollution playing havac in ‘modern’ lives. The computer, mobile phone, internet, cable TV etc. have become essential in our daily lives, but we are paying heavy toll for the comforts they provide.

Chapter 98: Humor in medicine

‘Humor is the best medicine’ but it may not be very ‘remunerative’. During conversation with a patient (or with anybody for that matter), it’s highly desirable to have a sense of humor, but it should be delicate, decent, fitting to the context and shouldn’t be rude, vulgar or too time consuming, remembering ‘brevity is the soul of a wit’.

It also helps to convey a message through a ‘sugar-coated’ pill and diffuses any tension in the atmosphere. Often they remember our humorous ‘anecdotes’ much longer than other explanations offered, with high technical knowledge. Can humor alone cure illness ? No, it can be used as an adjunct to other things and may address the emotional component.

If we want to treat only by humor, patient also may crack a joke and leave without paying the fees, making your practice itself a ‘joke’. To an elderly patient who says he never visited a Doctor before in his lifetime, the Doctor remarks in a lighter vain, ‘what will be the fate of Doctors, if every one is like you’.

Chapter 99: Euthanasia

‘Death with dignity is better than living with humiliation’.

It comes from a Greek expression, eu=good and thanatos=death (means ‘good death’).

Sometimes it’s used synonymous with ‘mercy killing’ or ‘assisted dying’.

Euthanasia is categorized in different ways, which includes voluntary, non-voluntary or involuntary.

Voluntary euthanasia is legal in some countries.

Non-voluntary euthanasia (patient’s consent unavailable) is illegal in many countries.

Involuntary euthanasia (without asking consent or against the patient’s will) is also illegal in all countries and is usually considered as a murder or homicide. We all remember the story of the legendary British nurse, Florence Nightingale, when she was young, she couldn’t see the suffering of a dog badly injured beyond salvage, decided to kill it, out of mercy.

Over the years, euthanasia had become the most active area of debate in bioethics. In some countries public controversy exists over the moral, ethical, and legal issues associated with euthanasia. Passive euthanasia (known as ‘pulling the plug’) is legal under some circumstances in many countries.

Active euthanasia, however, is legal or de facto legal in only a handful of countries (for example: Belgium, Canada and Switzerland), which limit it to specific circumstances and require the approval of counselors, Doctors and other specialists.

In some countries – such as Nigeria, Saudi Arabia and Pakistan – support for active euthanasia is almost non-existent. The advent of organ transplantation and redefining ‘brain death’ have created new dimention to this subject, more and more counties supporting the concept.

In 2018, passive euthanasia is made legal in India by the Supreme Court, under strict guidelines, by means of the withdrawal of life support to patients in a permanent vegetative state, after harvesting the usable organs.

The certification of brain death for purposes of organ donation, requires endorsement of four Doctors, the attending physician, a Doctor representing the hospital, an independent physician who is not involved in the care of the patient and a senior neurologist or neurosurgeon.

Chapter 100: Retirement

Doctor may superannuate from service (either govt or private) at a particular age, but retirement from profession is mostly voluntary or rarely due to some disability, physical or mental. An elderly Doctor may also stop practicing, if his residence is relocated to another place, state or country.

Depending upon the mindset and health condition there are many options to keep yourself busy, such as reading, writing a book, play games, do some business, do social service, visit places or just spend time with friends, family, children and grandchildren.

What we should not do, is keep nagging your family members for petty things, making their lives miserable and regret for your retirement. Another important action is passing on your ‘franchise’ to Doctors in your next generation, son, son-in-law, daughter, daughter-in-law or grandchildren.

We certainly don’t want our goodwill, earned over several decades, go waste or unutilized. If their speciality is different, another room, adjacent to yours, may be provided for them. If their subject is the same as yours, you may stagger timings and gradually transfer your practice to them, to retire in a phased manner.

Of course, if there’s no Doctor in your family willing to take over, you may ‘sell’ your practice to another Doctor, who is interested to run it or you may convert the place into some commercial outfit.

The Consultation Room